COVID-19 and Medicare Rule Changes: What You Need to Know

As the COVID-19 crisis unfolds, we’ve been waiting to see what changes federal officials might make to the nation’s healthcare system in order to accommodate a potential pandemic. We got some answers a few days ago when the Centers for Medicare and Medicaid Services issued an emergency declaration to healthcare providers. Most of these directives are designed to give healthcare facilities the ability to add more capacity in order to accommodate a potential influx of COVID-19 patients.

#1: Skilled Nursing Facilities

People covered by Medicare typically need to spend three midnights in a hospital in order to qualify for skilled nursing care. The emergency declaration allows hospitals to exempt Medicare patients from the three-night stay rule if the patient needs to be moved out of a hospital in order to make room for COVID-19 patients. Most affected are Medicare beneficiaries requiring skilled nursing facility care following a hospital stay, such as an older person who had a hip replacement.

This declaration also allows a provider to request more skilled care days than a Medicare patient is usually allowed. Typically, an individual can only get 100 skilled days per benefit period. In certain cases, we will be able to request additional skilled days without starting a new benefit period. For example, if someone has used their 100 days, but they still need care, we can work with the facility to request more time so long as they still medically need skilled care.

#2: Housing Acute Care Patients in Excluded Distinct Part Units

Medicare has strict rules about where a Medicare patient can be placed in a healthcare facility. The emergency declaration gives acute care facilities the freedom to move Medicare patients to different parts of the facility if needed in order to provide beds for individuals who are suffering COVID-19. If you or someone you love is moved, keep in mind that the facility should bill you as normal, even though the patient has been moved to a different area of the facility.

#3: Durable Medical Equipment

This emergency declaration gets rid of some of the hoops you must jump through in order to get durable medical equipment (DME). The Medicare system typically keeps a tight leash on DME, such as braces, walkers, and wheelchairs. There are strict rules about how often you can receive these items, how many you get, how they’re monitored, how they’re paid for, and how they’re returned to the provider. The emergency declaration waives some of those requirements. One example is the face-to-face requirement. You don't have to necessarily go to your doctor’s office to get orders for DME. This is good news for older adults who’ve been asked to stay at home in order to minimize their risk of exposure to the coronavirus. This directive also says that you don't need a new physician's order if you lose track of your DME and need a replacement because it’s likely that your doctor will be busy dealing with COVID-19 patients. Ultimately, if your DME is lost, destroyed, or rendered unusable, it’s now far easier to request a replacement. Of course, there’s a downside. Relaxing the requirements around DME means that we’re probably going to see a spike in the number of DME-related fraud cases. DME is one of the most common targets for Medicare fraud.

#4: Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a Hospital

This directive, similar to #2 above, says that Medicare patients in psychiatric units can be moved to other parts of a facility in order to free up beds for COVID-19 patients, as long as the Medicare patients receive the same level of care that they would have received in their original location. The facility should bill Medicare patients as normal, even though they’ve been moved to a different area of the facility. Double check your bills to make sure the facility has charged the patient correctly.

#5: Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a Hospital

This directive is very similar to #2 and #4 above. Medicare patients in rehabilitation units can be moved to other parts of a facility in order to free up beds for COVID-19 patients, if the Medicare patients receive the same level of care that they would have received in their original location. The facility should bill Medicare patients as normal, even though they’ve been moved to a different area of the facility.

#6: Supporting Care for Patients in Long-Term Care Acute Hospitals

A person affected by COVID-19 is usually in the hospital more than 25 days. This directive says that Medicare will continue to pay the hospital for the care of Medicare beneficiary with COVID-19 who ends up staying for more than 25 days.

#7: Home Health Agencies

This directive makes it easier for people to retain their home health services if the order for those services happens to expire during the timeframe covered by the emergency declaration period. This is important for Medicare beneficiaries because older adults who are staying at home in order to minimize exposure to the virus. The emergency declaration means they can get their home health orders renewed without seeing their doctor.

#8: Provider Locations

This directive allows out of state healthcare providers to practice in another state if they hold a similar licensure in their home state. During normal circumstances, a provider can only provide services in the state where he or she is licensed. The emergency declaration adds capacity to the healthcare system by allowing healthcare professionals to cross state lines if needed to provide treatment in areas with more COVID-19 cases.

#9: Provider Enrollment

This directive, designed to quickly ramp up the number of Medicare providers, waives several screening requirements that non-certified Medicare Part B suppliers need to meet in order to obtain temporary billing privileges. The directive eliminates the application fee for providers, which isn’t that big of a deal. More concerning is the fact that CMS is waiving two screening criteria that often eliminate the fraudsters: criminal background checks and site visits. As many of you know, I started my career working on Medicare fraud cases. Waiving these screening requirements while also loosening DME requirements is a recipe for fraud, in my opinion. I've already seen fraud messages about COVID-19 coming from the state. One scam involves so-called free COVID supplies. A scammer calls and says, “To get your free COVID supplies from Medicare, just give me your Medicare card number.” If you’re on Medicare or looking after someone who is, be on the lookout for these kinds of scams.

#10: Medicare appeals in Fee for Service, MA and Part D

Medicare normally has very strict requirements for appeals and a limited window of opportunity to file an appeal. The emergency declaration waives some of these requirements and gives you more time to appeal. If you’ve been sitting on an appeal and are worried that you’ve missed the deadline to file, it’s worth the call to the person who advises you on your Medicare coverage to see if you can still file your appeal. Even if you're filing the appeal yourself, go ahead and send it in. It's worth a try.

#11: Medicaid and CHIP

You probably won’t notice much of an impact from this directive, which gives the government the right to waive certain Medicare, Medicaid and Children’s Health Insurance Program (CHIP) authorities under Section 1135 of the Social Security Act during a state of emergency. We call this the 1135 provision. This directive makes it possible for a state to make temporary changes to their Medicaid program in response to the emergency, such as expanding their Medicaid program, changing the way federal Medicaid funds are allocated, or suspending certain requirements for programs, such as a fee for service or requirements for certain pre-admission and annual screenings for nursing home residents. The goal is to free up money and resources to direct toward the emergency.

The Big Takeaway

Everyone can take a deep breath. Even If you’re on Medicare, you shouldn’t see any changes in your care. Things may be a little different as the system adjusts to add the flexibility needed to deal with the possibility of an influx of COVID-19 patients. Your providers may move you around. They may act a little differently. You may not be in your usual rehab facility. But you're going to be billed appropriately and you're going to get the care you need.

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