Published: March 12, 2020; Last Updated: June 4, 2020
Evolent continues to closely monitor the outbreak and spread of Coronavirus Disease 2019 (COVID-19). COVID-19 has been declared a national public health emergency by the U.S. Department of Health and Human Services (HHS), a global pandemic by the World Health Organization, and a national emergency under the Stafford Act. The health of the public, patients, physicians and other clinical and administrative staff is of the utmost importance. This Resource Center provides links to several key resources from federal agencies to support your efforts. We encourage you to frequently check these resources to ensure you have the most up-to-date guidance. You should also be aware of announcements, legal requirements and guidance issued by your state and locality, as they may vary.
Changes to CMS Innovation Center Models
On June 3, CMS announced several changes to its Innovation Center payment models given the COVID-19 pandemic, including several that Evolent and other value-based care stakeholders have advocated. These include mitigating downside risk during the public health emergency and/or carving out COVID-19 episodes of care from model participants’ financial reconciliations in certain cases. CMS is also making some changes to quality reporting requirements and the timelines for new and existing payment models, including extending the Next Generation ACO model and Oncology Care Model each for an additional year and adding a 2022 start date to the Direct Contracting model (in addition to delaying the 2021 start date from January to April). The full table of changes by model is available here.
New Flexibilities Under Federal Health Programs
The national public health emergency declarations made by the President and HHS Secretary allow federal agencies to waive or modify certain federal requirements to address the emergency. CMS has announced several such waivers, some of which are also supported by provisions in recently enacted stimulus bills.
- CMS Flexibilities for Physicians and Other Providers
- Emergency Declaration Blanket Waivers for Health Care Providers
- Exceptions and extended deadlines for certain Medicare quality reporting programs
- Streamlined provider enrollment process
- Supports for hospitals and the health care workforce, paperwork reduction and expanded access to telehealth
Medicare Shared Savings Program Flexibilities
In two recent interim final regulations with comment period (IFC) published by CMS – March interim final rule [CMS-1744-IFC] and April interim final rule [CMS-5531-IFC] – the Agency has laid out several policies intended to address potential pandemic-related impacts for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP). While the regulations do have a 60-day public comment period, they are in effect now and retroactively dating back to January or March of this year as specified in the regulations. In the IFCs, CMS is:
- Clarifying that the MSSP “Extreme & Uncontrollable Circumstances” policy removes downside risk for each month of Public Health Emergency as declared by the HHS Secretary dating back to January 2020.
- Carving out COVID-19 “episodes of care” – costs of inpatient services through one month of outpatient services following hospital discharge for patients with COVID-19 – from participating ACOs’ performance year expenditures, benchmark updates, and revenue calculations for the loss sharing limit (two-sided risk BASIC Track ACOs).
- Closing this year’s MSSP application cycle to new entrants for the 2021 performance year and allowing ACOs with agreements ending this year to either renew into a new five-year agreement or extend their current agreement for a fourth year under their existing historical benchmark.
- Allowing BASIC Track ACOs to remain in their current track for 2021 and then move up to the level they would have been at in 2022.
- Temporarily redefining “primary care services” used for beneficiary alignment to the ACO to include services provided virtually through telehealth, virtual check-ins, e-visits or telephone. As described on our “Coding, Coverage and Reimbursement Resources” webpage, CMS also expanded the services that can be provided using audio-only telephone communication and has increased the reimbursement rates for some of these services. See the “Payment for Audio-Only Telephone Evaluation and Management Services” section on pages 137-141 of CMS’s April interim final rule [CMS-5531-IFC] and the full list of telehealth codes (last updated on April 30, 2020) here.
Read this April 29 fact sheet for more details.
Stay up-to-date on all the new waivers, flexibilities and other COVID-19 related policy changes by frequently visiting the CMS Current Emergencies and Partner Toolkit web pages. (Note: You may need to refresh your browser to display new content.)
President Trump’s March 13, 2020 national emergency declaration authorized the Federal Emergency Management Agency (FEMA) to use its disaster relief funds (~$40 billion) to aid in the response.
In addition, the federal government has enacted three major relief bills in response to the pandemic:
Phase 1: Coronavirus Preparedness & Response Supplemental Appropriations Act: $8.3 billion in emergency funds, including to the CDC, National Institutes of Health (NIH) and Food and Drug Administration (FDA) to support public health efforts and vaccine research and development.
- 6.2% increase in federal match for Medicaid coronavirus spending and a state option to receive a 100% federal match for COVID-19 testing services for uninsured individuals through their Medicaid programs.
- Requiring insurers in federal programs (Medicare, TRICARE, VA, Indian Health Service) to cover tests and related services without cost-sharing or prior authorization requirements.
- $1 billion to reimburse costs associated with testing uninsured individuals.
- Other provisions include paid sick leave, enhanced unemployment insurance, expanded nutrition assistance, and enhanced health care workforce safety standards.
Phase 3: $2 Trillion CARES Act
- $349 billion for small business “Paycheck Protection Program” loans of up to $10 million to support payroll, mortgage, rent and utility payments—forgivable if certain conditions are met.
- $454 billion for the U.S. Treasury Department to make loans, loan guarantees and other investments in Federal Reserve programs and facilities to support eligible businesses, States and municipalities; e.g., the Main Street Lending Program offers 4-year loans to companies in good financial standing before the crisis that employ up to 10,000 workers or have revenues of less than $2.5 billion. Also, see the Treasury Department’s provisions on payroll tax deferral and the employee retention credit here.
- 2% Medicare reimbursement bump from May through December
- 20% Medicare add-on payment for COVID-19 hospital inpatient DRGs
- $100 billion emergency fund to reimburse providers for expenses or lost revenues due to coronavirus
- $16 billion for the Strategic National Stockpile
- $1 billion for purchases under the Defense Production Act
Under the national Public Health Emergency, CMS also expanded its Accelerated and Advanced Payment Program. This expansion allowed health care providers to receive up to three months’ pre-payment of historical Medicare fee-for-service billings (or six months for hospital providers) with recoupment to begin after 120 days. CMS announced on April 26 that it has already paid $100 billion to about 45,000 applicants, and that the application period is now closed. See a CMS fact sheet for details.
Phase “3.5”: CARES Act Replenishment
Congress and the President reached a $484 billion interim deal, signed into law on April 24, to replenish CARES Act funds. Among the new funds provided:
- $321 billion for the Paycheck Protection Program PPP loans
- $50 billion for SBA Economic Injury Disaster Loans (EIDL) Program, $10B for EIDL grants, and $2B for SBA administrative/staffing costs to implement.
- $100 billion for HHS, including $75 billion to the Provider Relief Fund to cover increased expenses and lost revenue and $25 billion for coronavirus testing. Of this $25 billion, $11 billion was intended for states, localities, territories, and tribes to develop, purchase, administer, process, and analyze COVID-19 tests, scale-up laboratory capacity, trace contacts, and support employer testing. Funds are also made available to employers for testing.
- The legislation also provided $1 billion more for the CDC, $1.8 billion for the NIH, $22 million for the FDA, $825M for community health centers and rural health clinics and up to $1 billion to cover testing costs for the uninsured.
Congressional leaders are currently debating phase 4 stimulus and recovery legislation.
Resources For States
CMS has produced several checklists, fact sheets and other tools aimed at making it easier for states to receive federal waivers and implement existing flexibilities in their Medicaid and CHIP programs. These could be used for a range of activities, including temporarily expanding certain services and coverage, easing certain requirements for providers or patients, or increasing provider reimbursement, among other temporary changes.