​​​​​​​​In a highly regulated field like healthcare, temporary waivers of certain regulations allow healthcare facilities to adjust and respond more quickly during a public health emergency. This Waiver Tracker provides status updates on federal and state waivers sought by IHA. 

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Color Coded Legend

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CONDITIONS OF PARTICIPATION AND REGULATORY WAIVERS


Agency


Waiver (and Entity)

Status

CMS

HIPAA Privacy Rule: 

No Administrative Sanctions or Penalties for Non-Compliance with HIPAA Privacy Rule. For 72 hours following a hospital’s implementation of a disaster protocol, the following requirements are waived:
- The requirements to obtain a patient's agreement to speak with family members or friends involved in the patient’s care;
- The requirement to honor a request to opt out of the facility directory;
- The requirement to distribute a notice of privacy practices;
- The patient's right to request privacy restrictions;
- The patient's right to request confidential communications.
 
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(March 16, 2020)

CMS

DME Replacement: 

When Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable or unavailable, contractors will have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required.


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(March 16, 2020)

CMS

Replacement Prescription Fills: 

Medicare payment may be permitted for replacement prescription fills (for a quantity up to the amount originally dispensed) of covered Part B drugs in circumstances where dispensed medication has been lost or otherwise rendered unusable or unavailable due to the emergency.


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(March 16, 2020)


CMS

Telehealth (links)


 
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(March 17, 2020)

CMS

Telehealth Expansion

- No Administrative Sanctions for Reducing or Waiving Cost-Sharing Obligations: OIG will not subject physicians and other practitioners to OIG administrative sanctions for arrangements that certain conditions.

- Waiver of Telehealth Geographic Limitation and Site Restriction: Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patient’s places of residence starting March 6, 2020. 

- Non-Public Facing Remote Communication with Patients: OCR will not impose penalties for noncompliance with the HIPAA Rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency.

 
- Pre-Existing Patient-Provider Relationship: HHS will not enforce through audit the requirement that a pre-existing patient relationship be in place to take advantage of the waiver.

 
- DEA – Prescribing Controlled Substances without In-Person Medical Evaluation: DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation if certain conditions are met. 

 

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(March 17, 2020)



CMS


 
Modification of Timeframe for Medicaid MCOs to Resolve Appeals
- Allows Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) in the FFS program pursuant to 42 CFR §405.942 and 42 CFR §405.962 (including for MA and Part D plans), as well as the MA and Part D Independent Review Entities (IREs) under 42 CFR §422.562, 42 CFR §423.562, 42 CFR §422.582 and 42 CFR §423.582, to allow extensions to file an appeal. CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.950 and 42 CFR §405.966 and the MA and Part D IREs to waive requests for timeliness requirements for additional information to adjudicate appeals.

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(March 30, 2020)


CMS

Hospitals, Psychiatric Hospitals, and CAHs

 
- EMTALA Enforcement: Allows hospitals, psychiatric hospitals, and CAHs to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, in accordance with the state emergency preparedness or pandemic plan.

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(March 16 and 26, 2020, supplemented March 30, 2020)

CMS
Hospitals, Psychiatric Hospitals, and CAHs

- EMTALA Enforcement: Allows hospitals, psychiatric hospitals, and CAHs to screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19, in accordance with the state emergency preparedness or pandemic plan.
-         newbutton2.pngFAQ clarifying requirements, flexibilities and considerations for hospitals and other providers during the pandemic (5/1/2020): Link here
- Verbal Orders under §482.23, §482.24 and §485.635(d)(3): Allows for additional flexibilities related to verbal orders where read- back verification is still required but authentication may occur later than 48 hours. This will allow for more efficient treatment of patients in a surge situation.
- Reporting Requirements: Waives requirement that hospitals report patients in an intensive care unit whose death is caused by their disease process but who required soft wrist restraints to prevent pulling tubes/IVs may be reported later than close of business next business day.
- Patient Rights: Waives requirements under 42 C.F.R. §482.13(d)(2) with respect to timeframes in providing a copy of a medical record, 42 C.F.R. §482.13(h) related to Patient visitation and 42 C.F.R. §482.13(e)(1)(ii) regarding seclusion, but only for hospitals which are considered to be impacted by a widespread outbreak of COVID-19.
- Sterile Compounding: Waives requirements under 42 C.F.R. §482.25(b)(1) and §485.635(a)(3) in order to allow used face masks to be removed and retained in the compounding area to be re-donned and reused during the same work shift in the compounding area only.
- Information Sharing for Discharge Planning for Hospitals and CAHs: Waives the requirement to provide detailed information regarding discharge planning, including the requirement that hospital, psychiatric hospital, and CAH must assist patients, their families, or the patient's representative in selecting a post-acute care provider by using and sharing data; CMS is maintaining, however, the discharge planning requirements that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals of care. 
- Discharge Planning for Hospitals: Waives all the requirements post-acute care services, to expedite the safe discharge and movement of patients among care settings, and to be responsive to fluid situations in various areas of the country. CMS is maintaining the discharge planning requirements that ensure a patient is discharged to an appropriate setting with the necessary medical information and goals. Waives the requirement that for those patients discharged home and referred for HHA services, or for those patients transferred to a SNF for post-hospital extended care services, or transferred to an IRF or LTCH for specialized hospital services, the hospital must: (1) include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are available to the patient; (2) must inform the patient or the patient's representative of their freedom to choose among participating Medicare providers and suppliers of post- discharge services and that and (3) discharge plan must identify any HHA or SNF to which the patient is referred in which the hospital has a disclosable financial interest, as specified by the Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital under Medicare.
- Medical Staff: Waives 42 C.F.R. §482.22(a) and §485.627(a) to allow for physicians whose privileges will expire to continue practicing at the hospital or CAH and for new physicians to be able to practice in the hospital or CAH before full medical staff/governing body review and approval.
- Medical Records Timing: Waives 42 C.F.R. §482.24(c)(4)(viii) and §485.638(a)(4)(iii). CMS to allow flexibility in completion of medical records within 30 days following discharge and for CAHs that all medical records must be promptly completed. This may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
- Flexibility in Patient Self Determination Act Requirements (Advance Directives): Waives the requirements at section 1902(a)(58) and 1902(w)(1)(A) for Medicaid, 1852(i) (for Medicare Advantage); and 1866(f) and 42 CFR 489.102 for Medicare, which require hospitals and CAHs to provide information about its advance directive policies to patients 
- Physical Environment: Waives certain requirements under the Medicare conditions at 42 C.F.R. §482.41 and §485.623 to allow for flexibilities during surges, such as permitting non-hospital buildings/space to be used for patient care and quarantine sites, provided that the location is approved by the State (ensuring safety and comfort for patients and staff are sufficiently addressed) and so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. This allows for increased capacity and promotes appropriate cohorting of COVID-19 patients.
- Telemedicine for Hospitals and CAHs: Waives the provisions related to telemedicine at 42 CFR §482.12(a) (8)–(9) for hospitals and §485.616(c) for CAHs, making it easier for telemedicine services to be furnished to the hospital’s patients through an agreement with an off-site hospital. This allows for increased access to necessary care for hospital and CAH patients, including access to specialty care
- Physician Services: Waives requirements under 42 CFR §482.12(c)(1)–(2) and §482.12(c)(4), which requires that Medicare patients be under the care of a physician. This waiver may be implemented so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. This allows hospitals to use other practitioners to the fullest extent possible. 
- Anesthesia Services: Waives requirements under 42 CFR §482.52(a)(5), §485.639(c) (2), and §416.42 (b)(2) that a certified registered nurse anesthetist (CRNA) is under the supervision of a physician in paragraphs §482.52(a)(5) and §485.639(c)(2). CRNA supervision will be at the discretion of the hospital and state law. This waiver applies to hospitals, CAHs, and Ambulatory Surgical Centers (ASCs). These waivers will allow CRNAs to function to the fullest extent of their licensure, and may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
- Utilization Review: Waives certain requirements under 42 CFR §482.1(a)(3) and 42 CFR §482.30 which address the statutory basis for hospitals and includes the requirement that hospitals participating in Medicare and Medicaid must have a utilization review plan that meets specified requirements.
- Written Policies and procedures for Appraisal of Emergencies at Off Campus Hospital Departments: Waives 42 CFR §482.12(f)(3), emergency services, with respect to surge facilities only, such that written policies and procedures for staff to use when evaluating emergencies are not required for surge facilities. This removes the burden on facilities to develop and establish additional policies and procedures at their surge facilities or surge sites related to the assessment, initial treatment and referral of patients. These flexibilities may be implemented so long as they are not inconsistent with a state’s emergency preparedness or pandemic plan.
- Emergency Preparedness Policies and Procedures: Waives requirement that hospital and CAH to develop and implement emergency preparedness policies and procedures, and provisions requiring that the emergency preparedness communication plans for hospitals and CAHs to contain specified elements with respect to the surge site.
- Quality Assessment and Performance Improvement Program: Waives 42 CFR §482.21(a)–(d) and (f), and §485.641(a), (b), and (d), which provide details on the scope of the program, the incorporation, and setting priorities for the program’s performance improvement activities, and integrated Quality Assurance & Performance Improvement programs (for hospitals that are part of a hospital system).
- Nursing Services: Waives 42 CFR §482.23(b)(4), which requires the nursing staff to develop and keep current a nursing care plan for each patient, and §482.23(b)(7), which requires the hospital to have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present.
- Food and Dietetic Services: Waives requirement at paragraph 42 CFR §482.28(b) (3), which requires providers to have a current therapeutic diet manual approved by the dietitian and medical staff readily available to all medical, nursing, and food service personnel.
- Respiratory Care Services: Waives requirements at 42 CFR §482.57(b)(1) that require hospitals to designate in writing the personnel qualified to perform specific respiratory care procedures and the amount of supervision required for personnel to carry out specific procedures.
- CAH Personnel Qualifications: Waives minimum personnel qualifications for clinical nurse specialists at paragraph 42 CFR §485.604(a)(2), nurse practitioners at paragraph §485.604(b)(1)–(3), and physician assistants at paragraph §485.604(c)(1)–(3), providing maximum staffing flexibility.  
- CAH Staff Licensure: CMS is deferring to staff licensure, certification, or registration to state law by waiving 42 CFR §485.608(d) regarding the requirement that staff of the CAH be licensed, certified, or registered in accordance with applicable federal, state, and local laws and regulations.
- CAH Status and Location: Waives requirement at 42 CFR §485.610(b) that the CAH be located in a rural area or an area being treated as being rural, allowing the CAH flexibility in the establishment of surge site locations.
- Temporary Expansion Locations: For the duration of the PHE related to COVID-19, CMS is waiving certain requirements under the Medicare conditions of participation at 42 CFR §482.41 and §485.623 (as noted elsewhere in this waiver document) and the provider based department requirements at §413.65 to allow hospitals to establish and operate as part of the hospital any location meeting those conditions of participation for hospitals that continue to apply during the PHE.
- CAH 25 Bed Limit and 96 Hour Stay Requirements
- Use of IRF, LTCH and IPH Units: CMS has determined it is appropriate to issue a blanket waiver to inpatient prospective payment system (IPPS) hospitals that, as a result of the emergency, need to house acute care inpatients in excluded distinct part units, where the distinct part unit’s beds are appropriate for acute care inpatient. CMS has also determined it is appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient psychiatric units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and unit. Furthermore, CMS has determined it appropriate to issue a blanket waiver to IPPS and other acute care hospitals with excluded distinct part inpatient rehabilitation units that, as a result of the emergency, need to relocate inpatients from the excluded distinct part rehabilitation unit to an acute care bed and unit.
- Flexibility for Inpatient Rehabilitation Facilities Regarding the “60 Percent Rule”: IRFs may exclude patients from the hospital’s or unit’s inpatient population for purposes of calculating the applicable thresholds associated with the requirements to receive payment as an IRF (commonly referred to as the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency and the patient’s medical record properly identifies the patient as such. In addition, during the applicable waiver time period, we would also apply the exception to facilities not yet classified as IRFs, but that are attempting to obtain classification as an IRF. 
-        Responsibilities of physicians in critical access hospitals (CAHs).;42 C.F.R. § 485.631(b)(2): Waives the requirement for CAHs that a doctor of medicine or osteopathy be physically present to provide medical direction, consultation, and supervision for the services provided in the CAH at § 485.631(b)(2). CMS is retaining the regulatory language in the second part of the requirement at § 485.631(b)(2) that a physician be available “through direct radio or telephone communication, or electronic communication for consultation, assistance with medical emergencies, or patient referral.” 

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(March 16 and 26, 2020, supplemented March 30,  2020; 
​Retroactive to March 1, 2020 )



CMS

Skilled Nursing Facilities

- 3 Day Qualifying Hospital Stay: Waives requirement for a 3-day prior hospitalization for coverage of a SNF stay provides temporary emergency coverage of SNF services without a qualifying hospital stay, for those people who are evacuated, transferred, or otherwise dislocated as a result of the effect of disaster or emergency.
- Minimum Data Set Assessments & Transmissions: Provides relief to SNFs on the timeframe requirements for Minimum Data Set assessments and transmission
- Staffing Data Submission: Provides relief to long term care facilities on the requirements for submitting staffing data through the Payroll- Based Journal system.
- Pre-Admission Screening and Annual Resident Review (PASARR): Waives the following requirements related to PASARR for nursing home residents who may also have a mental illness or intellectual disability (42 CFR §483.106(b)(4)): Level I screens are not required for residents when they are being transferred between NFs (inter-facility transfers) and staff cannot enter nursing facilities due to quarantine.
- Physical Environment: Provides that if the State has approved the location as one that sufficiently addresses safety and comfort for patients and staff, CMS is waiving requirements under §483.90 to allow for a non-SNF buildings to be temporarily certified as and available for use by a SNF in the event there are needs for isolation processes for COVID-19 positive residents which may not be feasible in the existing SNF structure to ensure care and services during treatment for COVID-19 is available while protecting other vulnerable adults.
- Resident Groups: Waives requirements at §483.10(f)(5) which allow for residents to have the right to participate in-person in resident groups.
- Training and Certification of Nurse Aids: Waives the requirements at§483.35(d) which requires that a SNF and NF may not employ anyone for longer than 4 months unless they met the training and certification requirements under §483.35(d).
- Physician Delegation of Tasks; 42 C.F.R. 483.30(e)(4): Waives the requirement in § 483.30(e)(4) that prevents a physician from delegating a task when the regulations specify that the physician must perform it personally.

- Physician Visits; 42 C.F.R. 483.30(c)(3): Waives the requirement at § 483.30(c)(3) that all required physician visits (not already exempted in § 483.30(c)(4) and (f)) must be made by the physician personally. 

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(March 16 and 26, 2020, supplemented March 30, 2020; Retroactive to March 1, 2020 )


 




CMS

Home Health Agencies 

- Minimum Data Set Assessments & Transmissions: Provides relief to Home Health Agencies on the timeframes related to OASIS Transmission (Extension of the 5-day completion requirement for the comprehensive assessment. Waives the 30-day OASIS submission requirement).
- MACs extend auto-cancellation date of RAPS for HHAs: To ensure the correct processing of home health emergency related claims, Medicare Administrative Contractors (MACs) are allowed to extend the auto cancellation date of Requests for Anticipated Payment (RAPs). 
- Home Health Initial Assessment Visit: Home health agencies can perform Medicare-covered initial assessments and determine patients’ homebound status remotely or by record review.
 - Onsite visits for HHA Aide Supervision:  Waives requirements at 42 CFR 418.76 (h) and 484.80(h), which require a nurse to conduct an onsite visit every two weeks.
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Allow occupational therapists (OTs) to perform initial and comprehensive assessment for  all patients; 42 C.F.R. 484.55(a)(2) and 484.55(b)(3): Waives the requirement that OTs may only perform the initial and comprehensive assessment if occupational therapy is the service that establishes eligibility for the patient to be receiving home health care. 
​​
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(March 16 and 26, supplemented March 30, 2020; Retroactive to March 1, 2020)

 
CMS

Hospice

- Requirement for Hospices to Use Volunteers is being waived (including at least 5% of patient care hours). 
- Comprehensive Assessments: Certain requirements related to update of the comprehensive assessments of patients. Hospices must continue to complete the required assessments and updates, however, the timeframes for updating the assessment can be extended from 15 to 21 days.  
- Non-Core Services are being waived for certain areas, including requirements for physical therapy, occupational therapy, and speech-language pathology. 
- Onsite Visits: Requirement that a nurse conduct on onsite visit every two weeks.
- Hospice aide competency testing allow use of pseudo patients; 42 C.F.R. 418.76(c)(1): Modifies the requirement in § 418.76(c)(1) that a hospice aide must be evaluated by observing an aide’s performance of certain tasks with a patient. 
- 12-hour annual in-service training requirement for hospice aides; 42 C.F.R. 418.76(d): Waives the requirement that hospices must assure that each hospice aide receives 12 hours of in-service training in a 12-month period. 

 
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(March 26, and supplemented March 30, 2020; ​ Retroactive to March 1, 2020  )



CMS

Extended Neoplastic Disease Care Hospitals

- CMS is allowing extended neoplastic disease care hospitals to exclude inpatient stays where the hospital admits or discharges patients in order to meet the demands of the emergency from the greater than 20-day average length of stay requirement, which allows these facilities to be excluded from the hospital inpatient prospective payment system and paid an adjusted payment for Medicare inpatient operating and capital-related costs under the reasonable cost-based reimbursement rules.
- Pre-Admission Screening and Annual Resident Review (PASARR): Waives 42 CFR 483.20(k) allowing states and nursing homes to suspend these assessments for new residents for 30 days
- Physical Environment: Waives requirements under 42 CFR 483.90 to temporarily allow for rooms in a long-term care facility not normally used as a resident’s room, to be used to accommodate beds and residents for resident care in emergencies and situations needed to help with surge capacity.
- Physician Visits in Skilled Nursing: Waives requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform in person visits for nursing home residents and allow visits to be conducted, as appropriate, via telehealth options.Facilities/Nursing Facilities
- Resident Roommates and Grouping: Waives requirements in 42 CFR 483.10(e) (5), (6), and (7) solely for the purposes of grouping or cohorting residents with respiratory illness symptoms and/or residents with a confirmed diagnosis of COVID-19, and separating them from residents who are asymptomatic or tested negative for COVID-19.
- Resident Transfer and Discharge: Waives certain requirements, allowing a long term care (LTC) facility to transfer or discharge residents to another LTC facility solely for the following cohorting purposes: (1) Transferring residents with symptoms of a respiratory infection or confirmed diagnosis of COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents; (2) Transferring residents without symptoms of a respiratory infection or confirmed to not have COVID-19 to another facility that agrees to accept each specific resident, and is dedicated to the care of such residents to prevent them from acquiring COVID-19; or (3) Transferring residents without symptoms of a respiratory infection to another facility that agrees to accept each specific resident to observe for any signs or symptoms of a respiratory infection over 14 days.

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(March 30, 2020; 
Retroactive to March 1, 2020)



​​
CMS
End-Stage Renal Dialysis (ESRD) Facilities

- Training Program and Periodic Audits: Waives requirement at 42 CFR §494.40(a) related to the condition on Water & Dialysate Quality, specifically that on-time periodic audits for operators of the water/dialysate equipment are waived to allow for flexibilities.
- Defer Equipment Maintenance & Fire Safety Inspections: Waives requirement at 42 CFR §494.60(b) for on-time preventive maintenance of dialysis machines and ancillary dialysis equipment and the requirements under §494.60(d) which requires ESRD facilities to conduct on-time fire inspections.
- Emergency Preparedness: Waives requirements at 42 CFR §494.62(d)(1)(iv) which requires ESRD facilities to demonstrate as part of their Emergency Preparedness Training and Testing Program, that staff can demonstrate that, at a minimum, its patient care staff maintains current CPR certification. Also waives requirement for maintenance of CPR certification during the COVID-19 emergency due to the limited availability of CPR classes. 
- Ability to Delay Some Patient Assessments: Does not waive subsections (a) or (c) of 42 CFR §494.80, but does waive the following requirements at 42 CFR §494.80(b) related to the frequency of assessments for patients admitted to the dialysis facility. CMS is waiving the “on-time” requirements for the initial and follow up comprehensive assessments within the specified timeframes. 
- Time Period for Initiation of Care Planning and Monthly Physician Visits: Modifies two requirements related to care planning, specifically: (1) 42 CFR §494.90(b)(2), which requires the dialysis facility to implement the initial plan of care within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session; and (2) §494.90(b)(4), which requires the ESRD dialysis facility to ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant providing ESRD care at least monthly, and periodically while the hemodialysis patient is receiving in-facility dialysis. 
- Dialysis Home Visits to Assess Adaption and Home Dialysis Machine Designation: Waives requirement at 42 CFR §494.100(c)(1)(i) which requires the periodic monitoring of the patient’s home adaptation, including visits to the patient’s home by facility personnel.
- Special Purpose Renal Dialysis Facilities (SPRDF) Designation Expanded: Authorizes the establishment of SPRDFs under 42 CFR §494.120 to address access to care issues due to COVID-19 and the need to mitigate transmission among this vulnerable population.
- Dialysis Patient Care Technician (PCT) Certification: Modifies the require ment at 42 CFR §494.140(e)(4) for dialysis PCTs that requires certification under a state certification program or a national commercially available certification program within 18 months of being hired as a dialysis PCT for newly employed patient care technicians.
- Transferability of Physician Credentialing: Modifies requirement at 42 CFR §494.180(c)(1) which requires that all medical staff appointments and credentialing are in accordance with state law, including attending physicians, physician assistants, nurse practitioners, and clinical nurse specialists.
- Expanding Availability of ESRD to Nursing Home Residents: Waives the following requirements related to Nursing Home residents - Furnishing dialysis services on the main premises. 
- Clarification for Billing Procedures: Typically, ESRD beneficiaries are transported from a SNF/NF to an ESRD facility to receive renal dialysis services. To keep patients in their SNF/NF and decrease their risk of being exposed to COVID-19, ESRD facilities may temporarily furnish renal dialysis services to ESRD beneficiaries in the SNF/NF instead of the offsite ESRD facility.

 


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(March 30, 2020; 
Retroactive to March 1, 2020)








CMS

Rural Health Clinics (RHC) and Federally Qualified Health Centers (FQHC)

- Certain staffing requirements; 42 C.F.R. 491.8(a)(6): Waives the requirement in the second sentence of § 491.8(a)(6) that a nurse practitioner, physician assistant, or certified nurse-midwife be available to furnish patient care services at least 50 percent of the time the RHC and FQHC operates. CMS is not waiving the first sentence of § 491.8(a)(6) that requires a physician, nurse practitioner, physician assistant, certified nurse-midwife, clinical social worker, or clinical psychologist to be available to furnish patient care services at all times the clinic or center operates. This will assist in addressing potential staffing shortages by increasing flexibility regarding staffing mixes during the PHE. 8 
- Physician supervision of NPs in RHCs and FQHCs; 42 C.F.R. 491.8(b)(1): Modifies the requirement that physicians must provide medical direction for the clinic’s or center’s health care activities and consultation for, and medical supervision of, the health care staff, only with respect to medical supervision of nurse practitioners, and only to the extent permitted by state law. The physician, either in person or through telehealth and other remote communications, continues to be responsible for providing medical direction for the clinic or center’s health care activities and consultation for the health care staff, and medical supervision of the remaining health care staff. This allows RHCs and FQHCs to use nurse practitioners to the fullest extent possible and allows physicians to direct their time to more critical tasks. 




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(April 10, 2020;
retroactive to
March 1, 2020)

CMS

newbutton2.pngIncrease Hospital Capacity - CMS Hospitals Without Walls 

- CMS is giving providers flexibility during the pandemic to increase the number of beds for COVID-19 patients while receiving stable, predictable Medicare payments. For example, teaching hospitals can increase the number of temporary beds without facing reduced payments for indirect medical education. In addition, inpatient psychiatric facilities and inpatient rehabilitation facilities can admit more patients to alleviate pressure on acute-care hospital bed capacity without facing reduced teaching status payments. Similarly, hospital systems that include rural health clinics can increase their bed capacity without affecting the rural health clinic’s payments.
- CMS is excepting certain requirements to enable freestanding inpatient rehabilitation facilities to accept patients from acute-care hospitals experiencing a surge, even if the patients do not require rehabilitation care. This makes use of available beds in freestanding inpatient rehabilitation facilities and helps acute-care hospitals to make room for COVID-19 patients.
- CMS is highlighting flexibilities that allow payment for outpatient hospital services -- such as wound care, drug administration, and behavioral health services -- that are delivered in temporary expansion locations, including parking lot tents, converted hotels, or patients’ homes (when they’re temporarily designated as part of a hospital).
- Under current law, most provider-based hospital outpatient departments that relocate off-campus are paid at lower rates under the Physician Fee Schedule, rather than the Outpatient Prospective Payment System (OPPS). CMS will allow certain provider-based hospital outpatient departments that relocate off-campus to obtain a temporary exception and continue to be paid under the OPPS. Importantly, hospitals may also relocate outpatient departments to more than one off-campus location, or partially relocate off-campus while still furnishing care at the original site.
- Long-term acute-care hospitals can now accept any acute-care hospital patients and be paid at a higher Medicare payment rate, as mandated by the CARES Act. This will make better use during the pandemic of available beds and staffing in long-term acute-care hospitals.



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(Approved April 30, 2020)

CMS

newbutton2.png​Healthcare Workforce Augmentation 

- Nurse practitioners, clinical nurse specialists, and physician assistants can now provide home health services, as mandated by the CARES Act. These practitioners can now (1) order home health services; (2) establish and periodically review a plan of care for home health patients; and (3) certify and re-certify that the patient is eligible for home health services. Previously, Medicare and Medicaid home health beneficiaries could only receive home health services with the certification of a physician. These changes are effective for both Medicare and Medicaid.
- CMS will not reduce Medicare payments for teaching hospitals that shift their residents to other hospitals to meet COVID-related needs, or penalize hospitals without teaching programs that accept these residents. This change removes barriers so teaching hospitals can lend available medical staff support to other hospitals.
- CMS is allowing physical and occupational therapists to delegate maintenance therapy services to physical and occupational therapy assistants in outpatient settings. This frees up physical and occupational therapists to perform other important services and improve beneficiary access.  
- Consistent with a change made for hospitals, CMS is waiving a requirement for ambulatory surgery centers to periodically reappraise medical staff privileges during the COVID-19 emergency declaration. This will allow physicians and other practitioners whose privileges are expiring to continue taking care of patients.




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(Approved April 30,  2020)​

​​CMS

newbutton2.pngDecrease Administrative Burden 

- CMS is allowing payment for certain partial hospitalization services – that is, individual psychotherapy, patient education, and group psychotherapy – that are delivered in temporary expansion locations, including patients’ homes.
- CMS is temporarily allowing Community Mental Health Centers to offer partial hospitalization and other mental health services to clients in the safety of their homes. Previously, clients had to travel to a clinic to get these intensive services. Now, Community Mental Health Centers can furnish certain therapy and counseling services in a client’s home to ensure access to necessary services and maintain continuity of care. 
- CMS will not enforce certain clinical criteria in local coverage determinations that limit access to therapeutic continuous glucose monitors for beneficiaries with diabetes. As a result, clinicians will have greater flexibility to allow more of their diabetic patients to monitor their glucose and adjust insulin doses at home.




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(Approved April 30, 2020)​
CMS

newbutton2.pngFurther Expand Telehealth in Medicare 

- For the duration of the COVID-19 emergency, CMS is waiving limitations on the types of clinical practitioners that can furnish Medicare telehealth services. Prior to this change, only doctors, nurse practitioners, physician assistants, and certain others could deliver telehealth services. Now, other practitioners are able to provide telehealth services, including physical therapists, occupational therapists, and speech language pathologists.
- Hospitals may bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is at home when the home is serving as a temporary provider based department of the hospital. Examples of such services include counseling and educational service as well as therapy services. This change expands the types of healthcare providers that can provide using telehealth technology. 
- Hospitals may bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home. 
- CMS previously announced that Medicare would pay for certain services conducted by audio-only telephone between beneficiaries and their doctors and other clinicians. Now, CMS is broadening that list to include many behavioral health and patient education services. CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits. This would increase payments for these services from a range of about $14-$41 to about $46-$110. The payments are retroactive to March 1, 2020.
- Until now, CMS only added new services to the list of Medicare services that may be furnished via telehealth using its rulemaking process. CMS is changing its process during the emergency, and will add new telehealth services on a sub-regulatory basis, considering requests by practitioners now learning to use telehealth as broadly as possible. This will speed up the process of adding services.
- As mandated by the CARES Act, CMS is paying for Medicare telehealth services provided by rural health clinics and federally qualified health clinics. Previously, these clinics could not be paid to provide telehealth expertise as “distant sites.” Now, Medicare beneficiaries located in rural and other medically underserved areas will have more options to access care from their home without having to travel
- Since some Medicare beneficiaries don’t have access to interactive audio-video technology that is required for Medicare telehealth services, or choose not to use it even if offered by their practitioner, CMS is waiving the video requirement for certain telephone evaluation and management services, and adding them to the list of Medicare telehealth services. As a result, Medicare beneficiaries will be able to use an audio-only telephone to get these services.




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(Approved April 30, 2020)​

ISDH HOSPITAL LICENSURE WAIVERS AND GUIDANCE


AGENCY

WAIVER (AND ENTITY)

STATUS

ISDH



 


 

​​

 

​​
COVID-19 National / State Emergency Hospital Blanket Waiver:  Conversion of Standard Patient Rooms to Negative Pressure Isolation Rooms
- Existing rooms converted to negative pressure must be inspected by the ISDH prior to use.
- For rooms converted prior to 3/21/2020, ISDH will conduct and "as converted" inspection.
- Link to Guidance:  Here
​Amended 4/8/2020: Paragraphs 8 and 9 of the Isolation Waiver are stricken and  replaced  with the following:

 
- 8. Before a facility may use a room as a patient room with negative pressure (“PRNP”), the facility must check and confirm that the room has negative pressure. For as long as the room is used as a PRNP, the facility shall implement and maintain some type of monitoring system/device/process to help ensure continuous negative pressure.
- 9. (a) Each PRNP must have a visual monitoring mechanism that displays the room’s pressure status. If no visual mechanism is available because of product shortages or other factors beyond the facility’s control, the facility shall check and log the pressure of the PRNP at least once daily using an alternate method of verification such as a handheld device (e.g., a Vaneometer or differential pressure meter or gauge), smoke test, tissue test or “ball in the wall.” (b) If any pressure check reveals that a PRNP does not have negative pressure, the facility shall place the patient in reverse isolation and take prompt steps to restore negative pressure. If negative pressure is not restored within four (4) hours, and the patient’s condition continues to warrant negative pressure, the facility must relocate the patient to a different PRNP.
- In all other respects, the Isolation Waiver is unchanged and remains in full effect.

 
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(March 21, 2020;
Amended March 22, 2020 and April 8, 2020;
Retroactive to March 6, 2020) Effective through 9/17/2020



 

 
ISDH
Second COVID-19 National / State Emergency Hospital Blanket Waiver: Patient Rooms
- Waives requirement of pre-approval for hospitals converting unused or unlicensed space to temporary patient rooms. 
- Specifies that room and units previously approved but not in current use may be operationalized without review or inspection.
- Link to Guidance:  Here

 
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(March 24, 2020; 
Retroactive March 6, 2020) Effective through 9/20/2020

 

 
ISDH
Third Emergency Order Granting Temporary Blanket Waivers for Hospitals: Blanket waiver of multiple sections of the Hospital Licensure Rules  
In order to utilize the waivers, Hospitals must:
- Declare a COVID-19 facility emergency; and 
- Notify the ISDH of the declaration.
- Link to Guidance:  Here

 
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(March 27, 2020; 
Retroactive March 6, 2020)​ Effective through  9/23/2020

 
ISDH

Guidance Concerning Liability for Healthcare Providers and Facilities  
- State and Federal laws regarding healthcare worker and volunteer immunity.
- Link to the Guidance: Here.  


ISDH COMPREHENSIVE CARE FACILITY WAIVERS AND GUIDANCE

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(April 3, 2020)


AGENCY


WAIVER (AND ENTITY)
STATUS


ISDH

Emergency Order Authorizing Temporary Personal Care Attendant Positions and Training for Nursing Homes
- Allows for the training of Personal Care Attendants to perform certain resident care procedures in nursing homes.
- Link to Guidance:  Here

 
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(March 21, 2020; Retroactive March 6, 2020)

 

ISDH
Second Emergency Order Granting Temporary Blanket Waivers for Comprehensive Care Facilities
Blanket waiver of multiple sections of the Comprehensive Care Facility Licensure Rules that:
- Waives living arrangement requirements to allow for more rapid resident moves as needed.
- Replaces the 30 day requirement for most notices of involuntary transfer or discharge with an “as soon as practicable” standard
- Extends from four (4) to eight (8) months the period of time a facility may use a trained-but-not-yet tested certified nurse aide.
- Extends the deadline for certified nurse aides to complete in-facility training from 120 to 240 days after the start of employment.
- Waives in-person physician visit schedules to allow for telemedicine and other means of contact (no relaxation of applicable duty or standard of care).
- Waives assorted group and outside activities usually required in a facility’s plan of activities for residents.
- Allows individuals to provide limited dining assistance if given specified training.
- Link to Guidance:  Here

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(March 21, 2020; Retroactive March 6, 2020)

ISDH
Third Emergency Order Granting Temporary Blanket Waivers for Comprehensive Care Facilities
- Blanket waiver the Comprehensive Care Facility Licensure Rules that waives the requirement that each employee must have a physical examination within one (1) month after the start of employment.
- Link to Guidance:  Here

 
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(March 23, 2020; Retroactive March 6, 2020)

 

ISDH
Fourth Emergency Order Granting Temporary Blanket Waivers for Comprehensive Care Facilities.

 
Blanket waiver of multiple sections of the Comprehensive Care Facility Licensure Rules that:
- Allows that any comprehensive care facility that has (1) declared a COVID-19 facility emergency and (2) notified ISDH of the declaration may: 
Render care and required services to a resident in any resident bed or room within the facility, without regard for whether the bed or room is certified or otherwise approved for a particular category of residents or reimbursement (e.g., Medicaid); and 
Render care and services to a resident relocated to unlicensed space within the facility, or to a different facility not licensed to provide skilled nursing care, provided that the relocating facility (1) immediately gives notice to ISDH and provides full details of the relocation (e.g., resident name, new location, expected length of relocation); (2) continues meeting all the resident’s care and safety needs; and (3) notifies ISDH when the resident returns to the resident’s prior room or to a different resident room in its licensed space.
- Waives portions related to remodels, structural changes and bed changes for any comprehensive care facility that has declared a COVID-19 facility emergency and notified ISDH of the declaration if done in accordance with the guidelines set forth in the Fourth Emergency Order.
- Permits an existing facility to relocate, convert, and reclassify beds and renumber rooms if done in accordance with the guidelines set forth in the Fourth Emergency Order.
- Waives access and visitation rights standards to the extent necessary to be accordance with guidance by the Centers for Medicare & Medicaid Services (“CMS”), ISDH and /or by an Executive Order of the Governor of Indiana.
- Link to Guidance:  Here

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(March 26, 2020; Retroactive March 6, 2020)

​​IDHS OCCUPANCY AND CONSTRUCTION WAIVERS

AGENCY

​​WAIVER (AND ENTITY)

STATUS



IDHS

Structures that meet the scope of this rule modification are exempt from the requirement to comply with the provisions of 675 IAC 12-4-11(b) so long as the proposed occupancy would not cause the structure to become unsafe particularly in regards to suitable means of egress and structural stability of the proposed occupancy. 

- Without modification, this rule prohibits buildings from undergoing a change of use without: (1) complying with the current rules for new construction for the proposed use; or (2) complying with Chapter 34 of the 2014 Indiana Building Code or 675 IAC 13. 


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(April 8, 2020)
IDHS
Extends the 30-day time limit to permit residential occupancy on the specified conditions for the duration of the public emergency. 
- Without modification, this rule, 675 IAC 12-4-11(f), allows Class 1 structures to be used for residential occupancy for up to 30 days without having to comply with the general change of use requirements if specified conditions are met. 

 

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(April 8, 2020)
IDHS
Exempts structures that meet the scope of this rule modification from the requirement to comply with the provisions of 675 IAC 12-4-12(a) so long as the addition or alteration does not make the structure unsafe. 
- Without modification, this rule, 675 IAC 12-4-12, requires additions or alterations to an existing structure must comply with the rules for new construction unless specifically exempted. 


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(April 8, 2020)

IDHS
Modifies the definition of temporary structure to include any structure that meets the scope of this rule modification to exempt these structures from the requirement to obtain a design release prior to construction. 
- This rule, 675 IAC 12-6-2(f), provides the definition for a temporary structure is in order to be exempt from the design release requirement. 


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(April 8, 2020)

EXECUTIVE ORDERS (EO) THAT IMPACT HEALTH CARE OPERATIONS

​​​AGENCY

WAIVER (AND ENTITY)

STATUS

EO 20-02
(GOV)



Declaration of Public Health Emergency
- Link to EO:  Here

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(March 6, 2020)

EO 20-04
(GOV)

Directs The Executive Director of the IDHS and the Commissioner of the ISDH to seek assistance from the federal government
- Link to EO:  Here

 
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(March 16, 2020)


EO 20-05
(GOV)



Various FSSA and ISDH Waivers

 
Allows FSSA to:
- Waive all premium requirements for HIP and CHIP;
- Suspend face to face requirement and allow telehealth for statewide Medicaid-covered services, mental health services, and substance use disorder treatment and prescribing;
- Modify or suspend provider staffing, enrollment and hiring requirements for provides and facilities enrolled with DMHA, DDRS, and DOA.
- Link to EO:  Here

 
Allows ISDH to:
- Allow involuntary relocation hearings to be held at locations other than the comprehensive care facility; and
- Waive the Certificate of Need requirements as necessary to respond to COVID-19.
- Link to EO:  Here

 

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(March 19, 2020)



EO 20-08
(GOV)



Stay-at-Home Order unless necessary for Essential Activities, Essential Government Functions, or Essential Businesses and Operations 
- Link to EO:  Here


 
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(March 23, 2020)

EO 20-12
(GOV)



Various Waivers:
- Waives ISDH restrictions on release of communicable disease information.
- Allows for continued Medicaid payment for comprehensive care facilities when residents moved to an alternative setting.
- Suspends FSSA preferred drug list; , CHOICE eligibility requirement, and surety bond requirements for non-emergency medical transportation providers.  
- Grants FSSA the authority to approve an increased number of residents in intermediate care facilities and supported living settings.
- Suspends ratio limits for pharmacist supervision of pharmacy technicians.
- Suspends the 30-day limit to non-controlled substance medication refills and permits a one (1) time 90 day refill.
- Allows opioid prescribing via telemedicine in limited circumstances.
- Link to EO:  Here

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(March 26, 2020)

EO 20-13
(GOV)



Various healthcare-related issues including:
- Authorizing the suspension of the following requirements for temporary facilities approved by the Commissioner of the ISDH:
License requirement;
Pharmacy permit requirement for remote location; and
Pharmacy permit requirement for stand-alone pharmacy in a temporary facility
- Allow certain health care providers to practice without an active license.
- Directs the cancellation or postponement of elective procedures.
- Allows the use of audio-only telemedicine.
- Link to EO:  Here

 
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(March 30, 2020)



EO 20-17
(GOV)




Extends all Executive Orders to 5/5/2020 except for certain provisions which specifically expire prior to 5/5/2020
​​
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(April 3, 2020)

MEDICARE, MEDICAID, AND INSURANCE WAIVERS

​​​AGENCY

WAIVER (AND ENTITY) STATUS

CMS

Practitioner Locations:

CMS is temporarily waiving requirements that out-of-state practitioners be licensed in the state where they are providing services under certain circumstances.

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(March 30, 2020)


​​​
CMS

Practitioner Enrollment: 

CMS has a toll-free hotline to do the following:
- Enroll and receive temporary Medicare billing privileges.
- waive the following: application fee, criminal background checks associated with fingerprint-based criminal background checks, and site visits.
- Postpone all revalidation actions.

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(March 30, 2020)





The IHA COVID-19 Waiver Tracker was created in partnership with Hall, Render, Killian, Heath & Lyman, P.C.

​Page last updated: April 10, 2020