Published: March 12, 2020; Last Updated: April 1, 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 now 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.
Review the latest information on:
- COVID-19 Clinical and Technical Guidance. Protecting patients and health care professionals
- Coding, Coverage and Reimbursement. ICD-10 codes, plan flexibility and more
- Additional Important Policy Updates. Impact on APMs and quality measurements, new federal funding, telehealth flexibility and guidance for states
COVID-19 Clinical and Technical Guidance
The Centers for Disease Control and Prevention (CDC) has developed a virtual Situation Room as a helpful resource for regular updates on this global situation. Specific guidance for health care professionals includes:
- What health care personnel should know about caring for patients with confirmed or possible COVID-19 infection
- Answers to frequently asked questions from health care providers
- Evaluation of patients under investigation
- Collection and submission of specimens
- Infection control and clinical care guidance (infection control guidance allows the use of facemasks, which protect the wearer from splashes and sprays, as a temporary alternative to respirators, which filter the air, for most medical services until demand for respirators decreases).
- Guidance for health care personnel with potential exposure
The Centers for Medicare and Medicaid Services (CMS) is coordinating closely with the CDC and has issued aligned, setting-specific guidance on screening, treatment and transfer procedures health care workers should follow to prevent the spread of COVID-19 in hospitals and their emergency departments, hospices, nursing homes and dialysis facilities. Nursing home guidance directs nursing homes to significantly restrict visitors and nonessential personnel, as well as restrict communal activities inside nursing homes. CMS has its own one-stop shop for information and updates on this public health emergency, which it frequently updates.
Limiting Elective Surgeries And Procedures
CMS has issued new guidance on limiting non-essential adult elective surgery and medical and surgical procedures, including all dental procedures, during the COVID-19 response. These actions are intended to reduce spread of the virus and preserve essential medical equipment and capacity.
Obtaining Personal Protective Equipment (PPE) and COVID-19 Testing
Health care organizations seeking access to PPE and testing can contact state and local health departments as an initial step. Direct outreach to manufacturers or seeking donated supplies are other potential channels.
CDC resources on PPE:
- Strategies to Optimize the Supply of PPE and Equipment
- Manufacturer list for N95 Respirator Masks
- Directory of State Health Departments
Coding, Coverage and Reimbursement
HCPCS Billing Codes
Starting in April, laboratories testing for COVID-19 can bill Medicare and other health insurers for services that occurred after February 4, 2020, using the newly created HCPCS code (U0001). This code is only to be used for the tests developed by the CDC. Labs performing non-CDC tests for SARS-CoV-2/2019-nCoV (COVID-19) can bill for them using a different HCPCS code (U0002). Local Medicare Administrative Contractors (MACs) recently published payment amounts for claims they receive for the new HCPCS codes in their respective jurisdictions until CMS establishes national payment rates. They are approximately $36 for the CDC test and $51 for the non-CDC test. These prices may vary slightly depending on the local MAC. (See test pricing data sheet.) As with other laboratory tests, there is no beneficiary cost sharing under Original Medicare.
The new ICD-10-CM code U07.1 COVID-19, will take effect in the U.S. on April 1, six months earlier than was originally planned. The CDC cited the unprecedented nature of the pandemic for the off-cycle update. Per the World Health Organization, the official name of the virus is severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), while the name of the disease it causes is coronavirus disease (COVID-19).
The American Medical Association approved a new CPT code for SARS-CoV-2 (COVID-19) lab testing, effective March 13. See the CPT assistant guide for detailed information.
Coding for Telehealth Reimbursement
For the duration of the pandemic, CMS is temporarily increasing reimbursement for telehealth visits so that it is equivalent to reimbursement for ALL in-person visits, even those that would have been conducted in a physician’s office. To be reimbursed at the in-person rate, providers should bill the place of service (POS) code as if the service was offered in person and then the -95 modifier to indicate it was a telehealth visit so CMS can track it.
Plan Design Flexibility
CMS issued a memo to Medicare Advantage organizations, Part D plan sponsors and Medicare-Medicaid plans on the flexibilities they can exercise under state disaster or emergency declarations to waive certain requirements to help prevent the spread of COVID-19. These flexibilities include:
- Waiving cost-sharing for COVID-19 tests
- Waiving cost-sharing for COVID-19 treatments in doctor's offices or emergency rooms and services delivered via telehealth
- Removing prior authorization requirements
- Waiving prescription refill limits
- Relaxing restrictions on home or mail delivery of prescription drugs
- Expanding access to certain telehealth services
Medicare Provider Enrollment Relief Related to COVID-19
CMS has issued an FAQ document on new provider enrollment flexibilities in Medicare, including toll-free hotline numbers available to provide expedited enrollment and answer questions related to COVID-19 enrollment requirements.
Other Coverage Resources
To ensure the public has clear information on coverage and benefits under CMS programs, the agency also released three fact sheets that cover diagnostic laboratory tests, immunizations and vaccines, telemedicine, drugs and cost-sharing policies.
- Medicare Fact Sheet Highlights. In addition to the diagnostic tests described above, Medicare covers all medically necessary hospitalizations, as well as brief "virtual check-ins," which allows patients and their doctors to connect by phone or video chat. Medicare beneficiaries living in rural areas may use communication technology to have full visits with their physicians. Next Generation ACOs and Medicare Shared Savings Program (MSSP) ACOs with prospectively aligned beneficiaries may utilize telehealth waivers to increase virtual visits. See "New Telehealth Flexibilities" below for more on recent Medicare telehealth expansions available to providers.
- Medicaid and Children's Health Insurance Program (CHIP) Fact Sheet Highlights. Testing and diagnostic services are commonly covered services, and laboratory and x-ray services are a mandatory benefit covered and reimbursed in all states. States are required to provide both inpatient and outpatient hospital services to beneficiaries. All states provide coverage of hospital care for children and pregnant women enrolled in CHIP. Specific questions on covered benefits can be directed to the respective state Medicaid and CHIP agency.
- Individual and Small Group Market Insurance Coverage. Existing federal rules governing health insurance coverage, including with respect to viral infections, apply to the diagnosis and treatment of COVID-19. This includes plans purchased through HealthCare.gov. Patients can contact their insurer to determine specific benefits and coverage policies. Benefit and coverage details may vary by state and by plan. States may choose to work with plans and issuers to determine the coverage and cost-sharing parameters for COVID-19 related diagnoses, treatments, equipment, telehealth and home health services and other related costs. Also see this FAQ document on essential health benefits.
Additional Important Policy Updates
Impact on Alternative Payment Models and Quality Measurement
CMS has announced it is granting exceptions and extensions from various quality reporting requirements in Medicare. These policies include extending the quality reporting deadlines for Medicare Shared Savings Program (MSSP) ACOs and the Merit-Based Incentive Payment System (MIPS) from March 31, 2020 to April 30, 2020. MIPS-eligible clinicians who do not submit any MIPS data by the April deadline will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year. Other hospital and post-acute care program exceptions and extensions are detailed in the announcement.
CMS is currently evaluating other relief options for APMs and QPP participants in 2020. The CMS Center for Medicare (CM) and Center for Medicare and Medicaid Innovation (CMMI) have reported that they are working on additional guidance for ACOs and CMMI model participants given COVID-19 concerns and new flexibilities available to providers. Evolent is actively communicating with CMS about the needs and concerns of our partners and will provide updates as new guidance is released.
The federal government has enacted two major relief bills in response to the pandemic. On March 6, 2020, the president signed an $8.3 billion emergency supplemental spending bill to combat the virus. The legislation includes $3 billion for vaccine R&D, $2.2 billion for the CDC (including $950 million to support state and local agencies), $836 million for the NIH and $61 million for the FDA. More than $400 million will be disbursed to states within the first 30 days of the bill's enactment, with each state receiving no less than $4 million. In addition, on March 13 President Trump declared a national emergency under the Stafford Act, which authorizes the Federal Emergency Management Agency (FEMA) to assist state and local governments and allows HHS to waive certain regulations and laws to more quickly deliver testing and care for coronavirus patients. FEMA, an agency within the U.S. Department of Homeland Security, controls $50 billion in federal funding set aside by Congress for disaster relief. FEMA could potentially use that funding to help build medical facilities and transport patients, among other measures.
The second major COVID-19 relief bill was enacted on March 18. In addition to requiring employers with 500 or fewer employees to provide more comprehensive sick and family leave benefits related to the pandemic, the package includes a 6.2% increase in state Medicaid matching funds. This could help to limit provider reimbursement cuts at a time when they are forced to delay high-margin procedures and provide more uncompensated care. The bill also seeks to remove financial barriers to COVID diagnosis by requiring that insurers pay for COVID-19 testing and related visits, as well as provide $1 billion to reimburse providers for costs of testing uninsured individuals.
On March 27, Congress passed the $2 trillion CARES Act economic stimulus package, containing several provisions that can support health care providers:
- expanded small business loans of up to $10 million to support payroll, mortgage, rent and utility payments
- 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
The law also codifies several policies related to the temporary telehealth expansion, including not requiring an established patient relationship (which CMS had already chosen not to enforce). In addition, the law includes new funding for medical supplies: $16 billion for the Strategic National Stockpile and $1 billion for purchases under the Defense Production Act to stimulate domestic production of supplies, such as masks, that have been running low.
The CARES Act has also made possible an expansion of Medicare's accelerated and advanced payment program. This expansion allows practices to receive up to three months pre-payment of historical Medicare billings with recoupment to begin after 120 days. Providers will continue to submit claims as normal during the 120-day period after receiving the advance payment. Applications can be submitted to your Medicare Administrative Contractors (MACs). See a CMS fact sheet for details.
For more on the new law, see this section-by-section summary of the CARES Act and supplemental appropriations bill, as well as the final bill text. Congressional leaders are discussing the potential for additional rounds of stimulus and recovery legislation as early as April and will also need to address certain health care extender policies again before November 30, 2020.
New Telehealth Flexibilities
CMS has issued new guidance for providers on temporary expanded Medicare telehealth benefits under the 1135 waiver authority, the coronavirus emergency supplemental spending bill and the national emergency declaration. Under this waiver, Medicare can pay for telehealth services in any health care facility, including a physician's office, hospital, nursing home or rural health clinic, as well as from a patient's home, effective March 6, 2020. A range of providers including physicians, nurse practitioners, clinical psychologists and licensed clinical social workers, will be able to offer telehealth to their patients under this temporary waiver. Additionally, the HHS Office of Inspector General is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs. Prior to this waiver, Medicare could only pay for telehealth on a limited basis: when the person receiving the service is in a designated rural area and when they received such services from an "originating site," such as a clinic, hospital or other eligible medical facility. Next Generation ACO waivers provided exceptions to these rules, allowing telehealth to be provided to aligned Medicare beneficiaries regardless of originating site or geography. MSSP regulations also provided exceptions to these rules, allowing telehealth to be provided to prospectively aligned Medicare beneficiaries regardless of geography, and allowing the originating site to be the patient's home.
In CMS's Fact Sheet and FAQ document on these new telehealth flexibilities, CMS provides clear guidance for providers on how they can provide and bill for Medicare telehealth visits, virtual check-ins and e-visits. The HHS Office for Civil Rights has announced it will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers who serve patients in good faith through nonpublic everyday communications technologies, such as FaceTime or Skype, during this nationwide public health emergency. Providers are encouraged to notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. Facebook Live, Twitch, TikTok and similar video communication applications are public facing, and should not be used in the provision of telehealth by covered health care providers.
These new flexibilities are designed to ensure Medicare beneficiaries, who are at a higher risk for COVID-19, are able to visit with their doctor from their home without having to go to a doctor's office or hospital, which puts themselves or others at risk. This change broadens telehealth flexibility without regard to the diagnosis of the beneficiary and is consistent with guidance from the CDC on practicing social distancing to reduce the risk of COVID-19 transmission. This change will help prevent vulnerable beneficiaries from unnecessarily entering a health care facility when their needs can be met remotely.
Widespread Regulatory Changes to Assist Hospitals and Providers
On March 30, 2020, CMS announced a series of new rules and regulatory waivers to help hospitals and health systems manage surges in COVID-19 cases. These include:
- Further promote telehealth by relaxing rules around where patients can receive these services, allowing a wider range of technology for telehealth encounters, and increasing reimbursement for these services. CMS will pay for more than 80 additional services, including emergency department visits, that are furnished by telehealth wherever the patient is. If video is not possible, providers can evaluate beneficiaries by telephone only. In addition, for the duration of the pandemic, CMS is temporarily increasing reimbursement for telehealth visits so that it is equivalent to reimbursement for ALL in-person visits, even those that would have been conducted in a physician's office (something Evolent health has advocated for). See telehealth coding guidance.
- Increase hospital capacity to handle an influx of patients by temporarily waiving federal requirements that hospitals provide services within their own buildings. Under the new rules, hospitals can receive hospital payments for patients transferred to outside facilities, even hotels or dormitories used to handle a surge in patients. CMS is also allowing doctor-owned hospitals to increase beds, giving ambulances permission to transport patients to a wider range of locations, and allowing dialysis facilities to establish facilities specific to patients with COVID-19. Health care organizations can set up testing sites exclusively for identifying COVID-19 positive patients, while Medicare will pay laboratory technicians to travel to a beneficiary’s for COVID-19 specimen collection.
- Expand the health care workforce to meet the needs of an influx of patients. This includes easing the process for providers to enroll in Medicare, allowing local private practice clinicians to be temporarily employed at a time when they have postponed nonessential services, and waiving requirements for a nurse to conduct an onsite visit every two weeks for home health and hospice.
- Reduce paperwork to let clinicians focus more on direct patient care. Among other changes, CMS is reducing information requests for oversight activities, reprioritizing scheduled program audits, and changing the calculation of Part C and D Star Ratings to account for disruptions to data collection.
Guidance 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.
The new resources include a Fact Sheet on Medicaid Telehealth Flexibilities (pursuant to state laws). States are not required to submit a state plan amendment (SPA) to pay for telehealth services if payments for services furnished via telehealth are made in the same manner as when the service is furnished in a face-to-face setting. A state would need an approved state plan payment methodology (and thus, might need to submit a SPA) to establish rates or payment methodologies for telehealth services that differ from those applicable for the same services furnished in a face-to-face setting. The fact sheet includes example SPA language.