Hospice: CMS Flexibilities to Fight COVID-19
Since the beginning of the COVID-19 Public Health Emergency, the Trump Administration has
issued an unprecedented array of temporary regulatory waivers and new rules to equip the
American healthcare system with maximum flexibility to respond to the 2019 Novel
Coronavirus (COVID-19) pandemic. These temporary changes will apply immediately across the
entire U.S. healthcare system for the duration of the emergency declaration.
The goals of these
actions are to 1) expand the healthcare system workforce by removing barriers for physicians,
nurses, and other clinicians to be readily hired from the community or from other states; 2)
ensure that local hospitals and health systems have the capacity to handle a potential surge of
COVID-19 patients through temporary expansion sites (also known as CMS Hospital Without
Walls); 3) increase access to telehealth in Medicare to ensure patients have access to physicians
and other clinicians while keeping patients safe at home; 4) expand in-place testing to allow for
more testing at home or in community based settings; and 5) put Patients Over Paperwork to
give temporary relief from many paperwork, reporting and audit requirements so providers,
health care facilities, Medicare Advantage and Part D plans, and States can focus on providing
needed care to Medicare and Medicaid beneficiaries affected by COVID-19.
Medicare Telehealth and Telecommunications Technology
• Hospice providers can provide services to a Medicare patient receiving routine home
care through telecommunications technology (e.g., remote patient monitoring;
telephone calls (audio only and TTY); and 2-way audio-video technology), if it is feasible
and appropriate to do so. Only in-person visits are to be recorded on the hospice claim.
• Face-to-face encounters for purposes of patient recertification for the Medicare hospice
benefit can now be conducted via telehealth (i.e., 2-way audio-video
telecommunications technology that allows for real-time interaction between the
hospice physician/hospice nurse practitioner and the patient).
Workforce
• Training and Assessment of Aides: CMS is waiving the requirement at 42 CFR
§418.76(h)(2) for Hospice and 42 CFR §484.80(h)(1)(iii) for HHAs, which require a
registered nurse, or in the case of an HHA a registered nurse or other appropriate skilled
professional (physical therapist/occupational therapist, speech language pathologist) to
make an annual onsite supervisory visit (direct observation) for each aide that provides
services on behalf of the agency. In accordance with section 1135(b)(5) of the Act, we
are postponing completion of these visits. All postponed onsite assessments must be
completed by these professionals no later than 60 days after the expiration of the PHE.
• Annual Training. CMS is modifying the requirement at 42 CFR §418.100(g)(3), which
requires hospices to annually assess the skills and competence of all individuals
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furnishing care and provide in-service training and education programs where required.
Pursuant to section 1135(b)(5) of the Act, we are postponing the deadline for
completing this requirement throughout the COVID-19 PHE until the end of the first full
quarter after the declaration of the PHE concludes. This does not alter the minimum
personnel requirements at 42 CFR §418.114. Selected hospice staff must complete
training and have their competency evaluated in accordance with unwaived provisions
of 42 CFR Part 418.
• Quality Assurance and Performance Improvement (QAPI). CMS is modifying the
requirement at 42 CFR §418.58 for Hospice and §484.65 for HHAs, which requires these
providers to develop, implement, evaluate, and maintain an effective, ongoing,
hospice/HHA-wide, data-driven QAPI program. Specifically, CMS is modifying the
requirements at §418.58(a)–(d) and §484.65(a)–(d) to narrow the scope of the QAPI
program to concentrate on infection control issues, while retaining the requirement
that remaining activities should continue to focus on adverse events. This modification
decreases burden associated with the development and maintenance of a broad-based
QAPI program, allowing the providers to focus efforts on aspects of care delivery most
closely associated with COVID-19 and tracking adverse events during the PHE. The
requirement that HHAs and hospices maintain an effective, ongoing, agency-wide, datadriven quality assessment and performance improvement program will remain.
• Waive requirement for hospices to use volunteers. CMS is waiving the requirement at 42
CFR §418.78(e) that hospices are required to use volunteers (including at least 5% of
patient care hours). It is anticipated that hospice volunteer availability and use will be
reduced related to COVID-19 surge and anticipated quarantine.
• Waived onsite visits for Hospice Aide Supervision: CMS is waiving the requirements at 42
CFR 418.76(h), which require a nurse to conduct an onsite visit every two weeks. This
would include waiving the requirements for a nurse or other professional to conduct an
onsite visit every two weeks to evaluate if aides are providing care consistent with the
care plan, as this may not be physically possible for a period of time.
Patients Over Paperwork
• Comprehensive Assessments: CMS is waiving certain requirements for Hospice 42 CFR
§418.54 related to update of the comprehensive assessments of patients. This waiver
applies the timeframes for updates to the comprehensive assessment (§418.54(d)).
Hospices must continue to complete the required assessments and updates, however,
the timeframes for updating the assessment may be extended from 15 to 21 days.
• Waive Non-Core Services: CMS is waiving the requirement for hospices to provide
certain non-core hospice services during the national emergency, including the
requirements at 42 CFR §418.72 for physical therapy, occupational therapy, and speechlanguage pathology.
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• Accelerated/Advance Payments: In order to provide additional cash flow to healthcare
providers and suppliers impacted by COVID-19, CMS expanded and streamlined the
Accelerated and Advance Payments Program, which provided conditional partial
payments to providers and suppliers to address disruptions in claims submission and/or
claims processing subject to applicable safeguards for fraud, waste and abuse. Under
this program, CMS made successful payment of over $100 billion to healthcare
providers and suppliers. As of April 26, 2020, CMS is reevaluating all pending and new
applications for the Accelerated Payment Program and has suspended the Advance
Payment Program, in light of direct payments made available through the Department
of Health & Human Services’ (HHS) Provider Relief Fund. Distributions made through the
Provider Relief Fund do not need to be repaid. For providers and suppliers who have
received accelerated or advance payments related to the COVID-19 Public Health
Emergency, CMS will not pursue recovery of these payments until 120 days after the
date of payment issuance. Providers and suppliers with questions regarding the
repayment of their accelerated or advance payment(s) should contact their appropriate
Medicare Administrative Contractor (MAC).
Medicare appeals in Fee for Service, Medicare Advantage (MA) and Part D
• CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent
Contractor (QICs) in the FFS program 42 CFR 405.942 and 42 CFR 405.962 and MA and
Part D plans, as well as the Part C and Part D Independent Review Entity (IREs), 42 CFR
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 42 CFR 405. 950 and 42 CFR 405.966
and the Part C and Part D IREs to waive requirements for timeliness for requests for
additional information to adjudicate appeals; MA plans may extend the timeframe to
adjudicate organization determinations and reconsiderations for medical items and
services (but not Part B drugs) by up to 14 calendar days if: the enrollee requests the
extension; the extension is justified and in the enrollee's interest due to the need for
additional medical evidence from a noncontract provider that may change an MA
organization's decision to deny an item or service; or, the extension is justified due to
extraordinary, exigent, or other non-routine circumstances and is in the enrollee's
interest 42 CFR § 422.568(b)(1)(i), § 422.572(b)(1) and § 422.590(f)(1);
• CMS is allowing MACs and QICs in the FFS program 42 C.F.R 405.910 and MA and Part D
plans, as well as the Part C and Part D IREs to process an appeal even with incomplete
Appointment of Representation forms 42 CFR § 422.561, 42 CFR § 423.560. However,
any communications will only be sent to the beneficiary;
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966
and MA and Part D plans, as well as the Part C and Part D IREs to process requests for
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appeal that don’t meet the required elements using information that is available 42 CFR
§ 422.562, 42 CFR § 423.562.
• CMS is allowing MACs and QICs in the FFS program 42 CFR 405. 950 and 42 CFR 405.966
and MA and Part D plans, as well as the Part C and Part D IREs, 42 CFR 422.562, 42 CFR
423.562 to utilize all flexibilities available in the appeal process as if good cause
requirements are satisfied.
• Cost Reporting. CMS is delaying the filing deadline of certain cost report due dates due
to the COVID-19 outbreak. We are currently authorizing delay for the following fiscal
year end (FYE) dates. CMS will delay the filing deadline of FYE 10/31/2019 cost reports
due by March 31, 2020 and FYE 11/30/2019 cost reports due by April 30, 2020. The
extended cost report due dates for these October and November FYEs will be June 30,
2020. CMS will also delay the filing deadline of the FYE 12/31/2019 cost reports due by
May 31, 2020. The extended cost report due date for FYE 12/31/2019 will be July 31,
2020.
Additional Guidance
• The Interim Final Rules and waivers can be found at: https://www.cms.gov/aboutcms/emergency-preparedness-response-operations/current-emergencies/coronaviruswaivers .
• CMS has released guidance to describe standards of practice for infection control and
prevention of COVID-19 in hospices at https://www.cms.gov/files/document/qso-20-16-
hospice.pdf
• CMS has released guidance to providers related to relaxed reporting requirements for
quality reporting programs at https://www.cms.gov/files/document/guidance-memoexceptions-and-extensions-quality-reporting-and-value-based-purchasing-programs.pdf.
