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centers for medicare and medicaid services

This week, the Centers for Medicare and Medicaid Services (CMS) released a new update to the coverage and reimbursement of COVID-19 vaccines, vaccine administration and cost sharing under Medicaid, the Children’s Health Insurance Program, and the Basic Health Program Toolkit that was originally released on October 28 and first updated on November 23. This update includes additional information regarding vaccine administration reimbursement and outlines a streamlined review process that is available to states who are looking to expeditiously adjust vaccine administration reimbursement rates in their state plan.

CMS has also updated the toolkit with further clarification regarding managed care network adequacy and the phased distribution and administration of the Pfizer-BioNTech and other emergency use authorization (EUA) approved COVID-19 vaccines.


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office black telephone with hand isolated on white

On Thursday, March 5, 2020, the Centers for Medicare and Medicaid Services (CMS) will conduct a call to provide information about the May 2019 expansion of the Qualified Independent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration. This expansion now includes Part A providers that submit second level claim appeals (reconsiderations) to C2C Innovative Solutions, Inc. (the Part A East QIC). Topics of discussion will include benefits, who can participate, and how to participate. A question and answer session will follow the presentation. Attendees may send questions in advance via email. Please include “Appeals Demonstration” in the subject line. Additional information can be obtained from the Original Medicare Appeals web page. Members interested in participating in the call must register in advance.

The Centers for Medicare and Medicaid Services (CMS) requires a statewide process to ensure providers are qualified to render services to waiver-funded individuals. The Provider Qualification Process described below outlines the steps the Assigned AE and provider must follow to meet these requirements and the steps Supports Coordinators take to transition individuals if needed. This communication does not describe the qualification process for SC organizations.

New Provider Requalification
Following the provider’s initial qualification date, all providers classified as New are to be requalified by the end of the following fiscal year as designated on the DP 1059. For example, if a New provider’s first Qualification Begin Date in HCSIS is 01/20/2017, the provider must be requalified by 06/30/2018, which is the end of the following fiscal year. A New provider’s status is updated from New to Existing after the provider is requalified.

Existing Provider Requalification Cycle
Once a provider is classified as Existing, the provider is to be requalified on a three-year cycle based upon the last digit of the provider’s MPI number. By 5/1, sixty days prior to the provider’s qualification 6/30 end date, the Qualification Status will change to Expiring. If the provider is not requalified by the end of the fiscal year (6/30), the Qualification Status will change to expired.

The qualification statuses in HCSIS are as follows:
Service Qualification Status

  • Qualified – The provider meets ODP’s qualification requirements
  • Not Requalified – Assigned AE changes the status from ‘Qualified’ or ‘Expiring’ to ‘Not Requalified,’ if the provider no longer meets ODP’s qualification requirements by 6/30
  • Not Qualified – HCSIS changes the status from ‘Not Requalified’ to ‘Not Qualified’ on 07/01 or ODP can change the status to ‘Not Qualified’ at any time, if the provider’s qualification is being terminated
  • Expiring – HCSIS would automatically change the status from ‘Qualified’ to ‘Expiring’ on 05/01, if the provider has not been requalified
  • Expired – HCSIS would change the status from ‘Expiring’ to ‘Expired’ on 07/01, if the provider has not been requalified

See ODP Announcement 20-007 for the full process and timeline.

The release of this communication obsoletes ODP Announcement 011-18 Provider Qualification Process.

On February 5, 2020, ninety-nine members of the House of Representatives signed and sent a letter to Seema Verma, Administrator, Centers for Medicare and Medicaid Services (CMS), that questions the proposed eight percent cut to therapy services. The proposed cut was included in the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) final rule that was published on November 15, 2019. The letter contained two questions asked of CMS, including the methodology and data that were used in this decision making. The responses to these questions were requested by February 21, 2020. Contact RCPA Rehabilitation Services Division Director Melissa Dehoff with questions.

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After conducting many reviews and examining the coverage policies of private payers, the Centers for Medicare and Medicaid Services (CMS) finalized a decision to cover acupuncture for Medicare patients that suffer from chronic low back pain. The increased reliance on opioids and the current opioid public health crisis were large contributors to this decision. Studies have shown that patients who have suffered from chronic low back pain, and were treated by acupuncture, showed significant improvements in both function and pain. Hence, a better alternative than prescription opioids. This expansion of options for pain treatment is a large piece of the Trump Administrations’ strategy for defeating the country’s opioid crisis.

Acupuncture is a treatment performed by practitioners who stimulate specific points on the body by inserting small thin needles through the skin. For the purpose of this decision, chronic low back pain is defined as:

  • Lasting 12 weeks or longer;
  • Nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease);
  • Not associated with surgery; and
  • Not associated with pregnancy.

Medicare will cover up to 12 sessions in 90 days, with an additional 8 sessions for those patients with chronic low back pain who demonstrate improvement. No more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing.

Office of Developmental Programs (ODP) Announcement 20-002 requests comments regarding Proposed Heightened Scrutiny Information for Residential Services locations. Comments are being sought on attachments #1–#3 until 11:59 pm on Monday, February 17, 2020.

To be compliant with the Centers for Medicare and Medicaid Services (CMS) Home and Community-Based Settings (HCBS) rule, ODP must identify and complete onsite reviews of all service locations that are presumed to have the qualities of an institution. The purpose of these onsite reviews will be to determine whether each service location can overcome the institutional presumption by either showing proof that the requirements contained in the CMS HCBS rule are currently met, or by ensuring the requirements will be met within a timeframe specified by ODP (but no later than March of 2022).

If ODP determines that the service location does not currently meet the requirements but has a plan to meet them within the timeframe specified by ODP, the service location must be submitted to CMS for a heightened scrutiny review. CMS will then determine whether the service location has the qualities of a home and community-based setting and does not have institutional qualities.

Homes that are identified as one of the following will require an onsite heightened scrutiny review by ODP due to having the potential of isolating individuals living in the home from the broader community:

  • Farmstead – These settings are often in rural areas on large parcels of land, with little ability to access the broader community outside the farm. Individuals who live at the farm typically interact primarily with people with disabilities and staff who work with those individuals. Individuals typically live in homes only with other people with disabilities and/or staff. Their neighbors are other individuals with disabilities or staff who work with those individuals. Daily activities are typically designed to take place onsite so that an individual generally does not leave the farm to access HCBS or participate in community activities. For example, these settings will often provide a place onsite to receive clinical (medical and/or behavioral health) services, day services, places to shop and attend church services, as well as social activities where individuals on the farm engage with others on the farm, all of whom are receiving Medicaid HCBS. While sometimes people from the broader community may come onsite, people from the farm do not go out into the broader community as part of their daily life. Thus, the setting does not facilitate individuals integrating into the greater community and has characteristics that isolate individuals receiving Medicaid HCBS from individuals not receiving Medicaid HCBS.
  • Gated Community – These settings typically consist primarily of people with disabilities and the staff that work with them. Often, these locations will provide residential, behavioral health, day services, social and recreational activities, and long-term services and supports all within the gated community. Individuals receiving HCBS in this type of setting often do not leave the grounds of the gated community in order to access activities or services in the broader community. Thus, the setting typically does not afford individuals the opportunity to fully engage in community life and choose activities, services and providers that will optimize integration into the broader community.

* Campus – These settings have multiple co-located and operationally related (i.e., operated and controlled by the same provider) service locations/homes/facilities that congregate a large number of people with disabilities together and provide for significant shared programming and staff, such that people’s ability to interact with the broader community is limited. This could include group homes on the grounds of a private Intermediate Care Facility (ICF) or numerous group homes co-located on a single site or in close proximity (multiple units on the same street or a court, for example).

More information published by CMS on the HCBS rule, including heightened scrutiny requirements, can be found here. Attachment 1 lists locations requiring an onsite heightened scrutiny review from ODP. Attachment 2 and Attachment 3 are the proposed tools for evaluating and reviewing the listed sites. Questions pertaining to this announcement and accompanying attachments may be directed to this email.


January 13, 2020

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

CMS Reduces Psychiatric Hospital Burden with New Survey Process
Streamlined process will improve quality of care for patients

Today, the Centers for Medicare & Medicaid Services (CMS) announced a streamlined survey and certification process for psychiatric hospitals, delivering on the Agency’s “Patients Over Paperwork” initiative. The full benefits of this initiative can be explored here. This new process will ensure safety and quality through more holistic and efficient hospital inspections that protect patients, while reducing burden for providers.

Currently, psychiatric hospitals surveyed by State Survey Agencies are subject to two separate onsite compliance surveys, one by the State Survey Agency (SSA) for compliance with the hospital requirements and one by an outside contractor selected by the SSA for compliance with two additional psychiatric hospital standards.

Beginning in March 2020, CMS will implement a streamlined process in which psychiatric hospitals will receive one comprehensive hospital survey performed by the SSA to review compliance with both hospital and psychiatric hospital participation requirements, allowing inspectors to take a broader view of a psychiatric hospital’s operations and better identify systemic quality issues.

“The policy of multiple inspections for psychiatric hospitals is emblematic of the absurd status quo in healthcare. For too long, fragmented and misaligned processes have increased burden and administrative costs,” said CMS Administrator Seema Verma. “Under President Trump’s leadership, CMS is upending the status quo and forging ahead with practical, commonsense changes to streamline our processes to reduce burden and improve oversight and patient safety, and reducing unnecessary administrative costs.”

To participate in Medicare, a psychiatric hospital is required to meet both general hospital Conditions of Participation (CoPs) and separate CoPs for psychiatric hospitals. CoPs are federal requirements that promote the health, safety and well-being of the patients being treated in these facilities. CMS is not making any changes to these safety and quality requirements.

Moving to a single survey process will benefit patients by ensuring psychiatric hospital services are evaluated in the context of the overall hospital survey program, making it easier for surveyors and the provider to identify and correct systemic quality issues that impact patient care. It also benefits providers by reducing the regulatory burden currently imposed on psychiatric hospitals because a single survey team conducting the survey will conduct, and only one report would be issued documenting any survey findings, instead of two.

CMS is notifying hospitals, SSAs and psychiatric hospital stakeholders of this upcoming change through a memorandum released today. This change does not affect accreditation organizations’ current methodologies for approving hospitals or psychiatric hospitals, or CMS’s criteria for approving accreditation organizations to survey such facilities. To ensure states are appropriately prepared to begin conducting these surveys in March 2020, CMS is developing an online training that will be released soon.

For more information about the change in the psychiatric hospital survey process and to see the memorandum, visit: https://www.cms.gov/httpswwwcmsgovmedicareprovider-enrollment-and-certificationsurveycertificationgeninfoadministrative/informational-notice-forthcoming-integration-psychiatric-hospital-program-hospital-program-and-state


Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS, @CMSgov, and @CMSgovPress.

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The Centers for Medicare and Medicaid Services (CMS) is seeking additional feedback and recommendations regarding the elimination of specific Medicare regulations that require more stringent supervision than existing state scope of practice laws, or that limit health professionals from practicing at the top of their license.

This request from CMS stems from President Trump’s Executive Order (EO) #13890: Protecting and Improving Medicare for our Nation’s Seniors, which directs the Department of Health and Human Services (HHS) to propose a number of reforms to the Medicare program. These reforms include those that eliminate supervision and licensure requirements of the Medicare program that are more stringent than other applicable federal or state laws and often limit health care professionals, such as Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRN) from practicing at the top of their professional license.

CMS did incorporate some of the recommendations previously submitted in several payment rules, including the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS), where one of the changes included redefining physician supervision for services furnished by Physician Assistants (PAs).

If members have additional recommendations on ways to reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience, please send them to this email with “Scope of Practice” in the subject line. Recommendations must be submitted by January 17, 2020.

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The Centers for Medicare and Medicaid Services (CMS) recently announced the availability of the inpatient rehabilitation facility (IRF) provider preview reports. These reports have been updated and contain information based on quality data submitted by IRFs between Quarter 3 of 2018 and Quarter 2 of 2019. The data will reflect what will be published on IRF Compare during the March 2020 update of the website.

Providers have 30 days (December 9, 2019 – January 9, 2020) to review their performance data. While corrections to the underlying data will not be permitted during this time, providers can request CMS to review their data during the preview period if they believe the quality measure scores that are displayed are inaccurate.

Additionally, providers are reminded that the data for the quality measure Percent of Residents or Patients that have new or worsened Pressure Ulcers (short stay), will continue to reflect data collected between Quarter 3 2017 – Quarter 2 2018, and will continue to be publicly displayed until the new Changes in Skin Integrity Post-Acute Care: Pressure Ulcer/Injury, is publicly displayed in fall 2020, as finalized in the fiscal year (FY) 2018 IRF PPS Final Rule.

As of the March 2020 refresh, CMS will no longer publicly display the measure Percent of Residents or Patients who were assessed and appropriately given the seasonal influenza vaccine (short stay), as finalized in the FY 2019 IRF PPS Final Rule. This change is reflected in preview reports. Contact RCPA Rehabilitation Services Director Melissa Dehoff with questions.

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The Centers for Medicare and Medicaid Services (CMS) recently notified the Office of Long-Term Living (OLTL) of the approval of the OBRA Waiver amendment. The amendment is effective on January 1, 2020.

The changes in the approved amendment include:

  • Revise the Residential Habilitation service definition by modifying the number of hours that are defined as a day unit from a minimum of 12 hours to 8 hours.
  • Revise the service definitions of Job Finding, Job Coaching, Employment Skills Development, Career Assessment, and Benefits Counseling to address when employment services can be provided through the OBRA waiver, should the Office of Vocational Rehabilitation (OVR) have a waiting list (closed order of selection) or when OVR has not made an eligibility determination within 120 days.
  • Update the Abuse Registry Screening information to reflect that the Department of Human Services (DHS) utilizes IDEMIA as the data system to process fingerprint-based FBI criminal record checks, as well as other minor changes.
  • Revise cost neutrality estimates to reflect rate changes to the Personal Assistance Services (PAS) and Residential Habilitation waiver services.

If you have any questions, please contact the OLTL Bureau of Policy Development and Communications Management at 717-857-3280.