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Erik Kanter, Hoven Consulting
The Wisconsin Department of Health Services (DHS) has drafted an 1135 waiver to submit to CMS requesting the federal government make allowances for the state to comprehensively address COVID-19. While the contents of the full waiver can be found in the link above, Tim and I wanted to share the following highlights:
· 13.1 42 C.F.R. § 484.55(a). Allow home health agencies to perform certifications, initial assessments and determine patients’ homebound status remotely or by record review.
· 2.2 Waive pre-enrollment criminal background checks for Medicare-enrolled providers to temporarily enroll a provider for ninety (90) days or until the termination of the novel COVID-19 declaration of emergency, whichever is longer. (42 C.F.R. § 455.434); Following this temporary enrollment, DHS will complete the complete enrollment process, including conducting a criminal background check, within 90 days of this temporary enrollment.
· 2.3 Waive site visits to temporarily enroll a provider for ninety (90) days or until the termination of the novel COVID-19 declaration of emergency, whichever is longer. (42 C.F.R. § 455.432).
· 2.5 Waive the requirement that physicians and other health care professionals be licensed in the state in which they are providing services, so long as they have equivalent licensing in another state or are enrolled with Medicare (42 C.F.R.§ 455.412).
· 2.6 Allow providers to receive payments for services provided to affected beneficiaries in alternative physical settings, such as mobile testing sites, temporary shelters or other care facilities, including but not limited to, commandeered hotels, other places of temporary residence, and other facilities that are suitable for use as places of temporary residence or medical facilities as necessary for quarantining, isolating or treating individuals who test positive for COVID-19 or who have had a high-risk exposure and are thought to be in the incubation period or to expand overall capacity to meet high demand.
· 4.1 Suspend cost sharing for all Wisconsin Medicaid participants for the duration of the declared emergency.
· 4.2 Broadly waive any face-to-face requirements.
· 6.5 Waiver CMS Payment Error Rate Measurement (PERM) and Quality Control (QC) requirements to allow some flexibility regarding errors during the duration of the declared emergency.
· 6.6 Allow flexibility for the submission of electronic signatures on behalf of a member by application assistors if a signature cannot be captured in person. This would be in the case of individuals who are non-merit staff assisting individuals through the application process over the phone (who normally would be doing this assistance in-person).
· 8.8 Allow the State to waive requirements prohibiting the provision of home and community-based services to affected beneficiaries who are being served in an inpatient setting in order to enable direct care workers or other home and community-based providers to accompany individuals to any setting necessary (42 C.F.R. § 441(b)(1)(ii)).
· 8.13 Allow the State to restrict freedom of choice of provider (§ 1902(a)(23)(A)).
· 10.2.1.1 Approve the use of technology and physical barriers that limit exposure and potential spread of the virus, such as use of video and audio resources for limiting direct contact between physicians and other providers in the same clinical facility.
· 10.2.1.2 Permit treatment to occur in patient vehicles, assuming patient safety and comfort. Many facilities are standing up drive through specimen collection sites, we’d like to request basic evaluation and treatment be allowed in patient vehicles in order to prevent potential spread of the virus to the facility.
· 10.2.6 Medical Staff. 42 C.F.R. § 482.22(a); A-0341 So that physicians whose privileges will expire and new physicians can practice before full medical staff/governing body review and approval. This will keep clinicians on the front line and allow hospitals and health systems to prioritize patient care needs during the emergency.
· 10.3 Physician referral. Waive sanctions under section 1877(g) of the Social Security Act (relating to limitations on physician referral). This will allow hospitals to compensate physicians for unexpected or burdensome work demands (e.g., hazard pay), encourage multi-state systems to recruit additional practitioners from out-of- state, and eliminate a barrier to efficient placement of patients in care settings.
DHS has submitted the waiver to the legislature's Joint Committee on Finance for its approval, which is the normal process for submitting an 1135 waiver. We're trying to gain some information on the legislature's timeline. It is our understanding that due to certain requirements in statute, it may take a bill to actually allow DHS to submit the waiver, rather than just approval by the Joint Committee on Finance. We're doing our best to understand the full scope of the situation and will provide updates when we know more.
Any questions or follow-up on this or any other COVID-19 issues can be sent to firstname.lastname@example.org.
Governor Tony Evers, March 26, 2020
MADISON — Gov. Tony Evers today launched an initiative designed to get more personal protective equipment (PPE), such as gowns, gloves and masks, to those working on the frontlines of the response to the COVID-19 pandemic.
“It is absolutely imperative that our healthcare workers and first responders have the equipment they need to stay safe and healthy as they care for our communities. As we face a global shortage of PPE, and are competing with other states to acquire limited resources, I am calling on companies, schools, and other organizations that may have unused protective equipment sitting in their facilities to make those materials available to those who need it most,” Gov. Evers said. “The state appreciates any donations, but we are also prepared to pay a fair market value for large quantities of this equipment that are offered.”
Wisconsinites can now go to https://covid19supplies.wi.gov/Donations to either donate or sell large quantities of PPE to the State of Wisconsin. The State Emergency Operations Center (SEOC) will then work with distribute the PPE to communities that need it the most.
First responders and other non-medical organizations should communicate their PPE needs to their county or tribal emergency management office, which will then forward those requests to the SEOC for fulfillment. Medical facilities, including hospitals, nursing homes, assisted living facilities and clinics, should continue using the established process for requesting supplies from the Strategic National Stockpile (SNS).
“We are amazed at the outpouring of offers from businesses and other organizations who have already told us they want to help fill the critical need for this equipment across the state,” said Dr. Darrell L. Williams, Wisconsin Emergency Management administrator. “Our staff has already been working to review those offers of support, and our hope is this site will help to streamline that process going forward.”
“Wisconsin, like many other states, has a shortage of personal protective equipment due to the COVID-19 pandemic,” said DHS Secretary-designee Andrea Palm. “We are doing everything we can to get more protective equipment so our health care workers, first responders on the frontlines can protect themselves from COVID-19, and in turn, help keep all Wisconsinites safer.”
The state is currently seeking the following items:
• Surgical Gowns (S, L, XL, and XXL)
• Face/Surgical Masks (adult, pediatric)
• Gloves (Nitrile, Vinyl, or Butyl)
• N-95 Particulate Respirators
• Isolation Gowns
• Face Shields
• Tyvek Coveralls
• Foot Coverings
If organizations or businesses have quantities of fewer than 50 of any of these items, they are encouraged to donate them to local health organizations instead of going through the buyback website.
The SEOC and Department of Health Services continue working to supply medical facilities with supplies requested from the SNS. So far, the state has received about 104,680 N95 respirators, 260,840 face/surgical masks, 48,168 face shields, 40,512 surgical gowns, 192 coveralls, and 70,375 pairs of gloves from the SNS. The state has also requested assistance from the Federal Emergency Management Agency (FEMA) with purchasing supplies for use by first responders.
Today Wisconsin Governor Tony Evers issued a shelter in place order to be in effect from Wednesday, March 25 at 8:00am until Friday, April 24 at 8:00am. This means all non-essential in-person services will stop and Wisconsinites are discouraged from leaving their homes except for essential activities and to conduct work at essential business and operations as defined below. Note: The following is a summary. For exact language, please refer to the linked order.
Individuals may leave homes or residences to perform any of the following:
· Health and safety.
· Obtain Necessary supplies and services.
· Outdoor activity.
· Certain types of work at essential business and operations.
· Take care of others.
Essential Business and Operations
Individuals may leave their homes or residences to work at the following:
· Healthcare and Public Health Operations - Includes, but is not limited to: home health agencies and providers; hospitals; medical facilities; clinics; ambulatory surgery centers for response to urgent health issues or related COVID-19 activities;manufacturers, technicians, logistics, and warehouse operators and distributors of medical equipment, personal protective equipment (PPE),medical gases, pharmaceuticals, blood and blood products, vaccines, testing materials, laboratory supplies, cleaning, sanitizing disinfecting or sterilization supplies, and tissue and paper towel products; dental offices; pharmacies; public health entities, pharmaceutical, pharmacy, medical device and equipment, and biotechnology companies; healthcare information technology companies; organizations collecting blood, platelets, plasma, and other necessary materials; obstetricians, gynecologists, and midwife practices; eye care centers, including those that sell glasses and contact lenses; mental health and substance abuse providers; detoxification and alcohol or drug treatment programs and facilities; syringe access programs, and naloxone distribution programs; other healthcare facilities and suppliers and providers of any related or any ancillary health care services; entities that transport and dispose of medical materials and remains; personal care agencies; hospices; allied health providers;acupuncturists; massage therapists; chiropractors; and adult family homes.
· Essential Governmental Operations.
· Human Service Operations
· Essential Infrastructure
· Many others to be found in the order language
All previous emergency executive orders also remain in effect. Those can be found here.
We will continue to provide updates.
NAHC, March 23, 2020
Listen to NAHC President William A. Dombi discuss the impact of COVID-19 on the Disrupt podcast from Home Health Care News. Bill talks about what home health care workers need right now (PPE!) and what NAHC is doing to make sure our people are safe and quality care in the home remains at the center of the effort to slow and stop the spread of the coronavirus.
March 23, 2020
The Honorable Tony Evers
Governor, State of Wisconsin
115 East, State Capitol
Madison, WI 53702
Secretary-Designee Andrea Palm
Wisconsin Department of Health Services
1 West Wilson St, Room 650
Madison, WI 53703
Dear Governor Evers and Secretary-designee Palm,
First, thank you for the measures you have taken so far to address the COVID-19 pandemic. Your actions have pragmatically addressed this growing problem in the best interest of Wisconsin.
As you prepare to issue tomorrow's Safer at Home order, the Wisconsin Association for Home Health Care, Inc. (WiAHC) urges you to allow home health care agencies to continue to provide our essential, life-sustaining services throughout the public health emergency. Home health care agencies and the RNs and LPNs who deliver home health care services must be considered essential services under the order. The home health patients who rely on our services simply cannot afford to be without care during this time and our skilled nursing staff needs to continue to provide that needed care.
While we request home health care services be considered essential services, we also request you allow for following two changes to DHS 133 administrative code that will allow our skilled nursing staff to conduct certain home health visits telephonically:
· DHS 133.18 Supervisory visits.
o Current rule language: (1) If a patient receives skilled nursing care, a registered nurse shall make a supervisory visit to each patient's residence at least every 2 weeks. The visit may be made when the home health aide is present or when the home health aide is absent. If the patient is not receiving skilled nursing care, but is receiving another skilled service, the supervisory visit may be provided by the appropriate therapist providing a skilled service.
o Current rule language: (2) If home health aide services are provided to a patient who is not receiving skilled nursing care, or physical, occupational or speech-language therapy, the registered nurse shall make a supervisory visit to the patient's residence, when the home health aide is present or when the home health aide is absent, at least every 60 days to observe or assist, to assess relationships, and to determine whether goals are being met and whether home health services continue to be required.
o Our request is to allow for a grace period of an additional 14 days to conduct supervisory visits for both the 14-day requirement under sub. sec. 1 and the 60-day requirement under sub. sec. 2 while the state is under a public health emergency. Additionally, we request DHS allow agencies to conduct supervisory visits via telephone or videoconferencing while the state is under a public health emergency.
· DHS 133.20 Plan of care.
o Current rule language: (3) Review of plan. The total plan of care shall be reviewed by the attending physician, advanced practice nurse prescriber, or physician assistant, and appropriate agency personnel as often as required by the patient's condition, but no less often than every 60 days. The agency shall promptly notify the physician, the advanced practice nurse prescriber, or the physician assistant of any changes in the patient's condition that suggest a need to modify the plan of care.
o We request DHS allow home health care agencies to conduct any necessary visits from RNs associated with the 60-day review process to be done via telephone or videoconferencing while the state is under a public health emergency.
Thank you for your attention to these matters. If you have any questions, please contact Tim Hoven ( email@example.com) and me (firstname.lastname@example.org).
Erik KanterHoven Consulting, Inc.
Governor Evers announced today that he be issuing a “Safer at Home” order effective Tuesday, March 24. Organizations and individuals providing essential care and services will be allowed to continue travelling to and from work. This includes healthcare professionals, grocers and family caregivers. The full details of the order to be announced by the Governor’s office. Everyone else is asked to not take any unnecessary trips, and to limit travel to essential needs such as getting medications and groceries.
This order is based on the advice and counsel of public health experts, healthcare providers and first responders on the front line of our state’s response to the pandemic. These unprecedented measures are necessary to reduce rate of spread in COVID-19 cases. We must do everything we can to keep our healthcare systems from becoming overwhelmed, and protect both the public and essential healthcare workers who are taking care of the critically ill.
NACH, March 20, 2020
On Friday, March 20, the Centers for Medicare & Medicaid Services (CMS) held a call with home health organizations to discuss recent developments related to the novel coronavirus COVID-19. Even though the call was specific to home health agencies there hospice questions addressed, as well.
CMS indicated it plans to hold similar calls weekly, but these have not yet been scheduled. Stay tuned to NAHC Report for additional information.
This was a short 30-minute call in which CMS briefly summarized recent activity related to the 1135 waivers and home health providers and then responded to questions from callers. The questions and answers are below. “We” in the answers is CMS.
Q: Do our agencies need to submit 1135 waiver requests or is a request submitted by a department of health or association on our behalf sufficient?
A: If your concerns are listed on the waiver requests it is fine. No need to send another. When we look at specific provider requests, we do look at whether it would be good to have it applicable to all.
Q: Does the 1135 waiver that allows telehealth for F2F visits include both home health and hospice, and if included will there be a code added for COVID19 to allow for billing?
A: Telehealth for the F2F encounter for home health is allowed under the existing waiver. We are looking to update this on our website and FAQ pages and should see this later today. We are continuing to look at what additional flexibilities that we have in regard to hospice, but we are not able at this time to make additional waivers in regard to the 1135 process. We are looking closely and very seriously to these concerns . Also, by regulation, the cost of remote patient monitoring, if used to augment the patient care process, is allowed on the home health cost report.
Telehealth cannot be used to substitute for an in person visit – statute prohibits this, but we are still looking closely to see what flexibilities we have.
Q: I think I can infer from your last statement that hospice is not part of the 1135 waiver and I am puzzled by this because it is inconsistent with social distancing guidance and I am curious if soon we can anticipate a waiver covering these F2F visits for certification, and if it does occur will it be retroactive?
A: The statute under which we operate is very different between home health and hospice. It relates to section 1834(m) which does not include hospice telehealth. The 1135 waiver specifically references our ability to provide telehealth waivers specific to 1834(m). We are thinking as creatively as we can as to whether we have additional flexibility under this authority or other types of authorities.
Q: So in order for our medical directors to feel like we are providing care responsibly we feel it is mandatory that we forgo F2F visits to protect the health of our patients and our staff when we already have a staff person on site who can give the information to the physician for a hospice certification decision.
A: This is along the lines of our thinking and we continue to look at this scenario.
Q: Do you think hospices will be penalized for trying to protect the safety of their staff and their patients?
A: We certainly understand the need for safety and we are making efforts to try to align the payment policies, processes and regulations with this need.
Q: Please reiterate what you are saying about telehealth for F2F for home health and home health homebound status – will it be extended to cover COVID-19?
A: Homebound – in regard to individuals contraindicated to leave their home in this COVID emergency, we are looking to see what additional flexibilities we might be able to grant. With regard to the F2F visit, it can be performed by teleahtlh in accordance with the 1135 waiver. With regard to aspects of other telehealth visits – telehealth cannot be substituted for other in-person visits.
Q: Providers are increasingly low on masks and other supplies. Will you change regulations as they get increasingly lower?
A: We understand the concern across all settings about this shortage and we are working with the CDC to look at guidelines and see how they can be modified. We do encourage you to look at state and local systems as they have the ability to manage the stockpile.
Additional questions can be submitted to email@example.com.
President Signs Coronavirus Response Act with Emergency Paid Sick Leave
On February 26, Wisconsin Governor Tony Evers vetoed Senate Bill 821, which passed both the State Senate and State Assembly on February 20. Just two Democratic lawmakers, Rep. Steve Doyle of Onalaska and Nick Milroy of South Range, voted for the bill. Every Republican lawmaker supported the legislation.
The bill aimed to cut taxes by $250 million, which, according to estimates, would have reduced the average tax bill by over $100. The cut would have been funded by the positive revenue numbers reported earlier this year.
On February 26, Governor Tony Evers vetoed the legislation on February 26 citing concerns that the tax cuts were made at the expense of further investment in public schools.
In his veto message, Evers stated, “…[T]his bill fails to acknowledge or address the continued, inordinate burden that has been placed on our public schools, local governments, and Wisconsin families. Since 2011, nearly one million Wisconsinites have voted to raise their own taxes to support local schools. In 2018 alone, voters approved more than $2 billion in debt and revenue increases for local schools. This is not sustainable.”
The statement went on to say, “We do not have to choose between funding for our kids and our schools and providing property tax relief—we can and should do both.” The move was expected and consistent with Evers’ prioritization of education funding.
The Governor’s veto was met with criticism from Republican legislative leaders. “It seems that Governor Evers is obsessed with growing government more than addressing the needs of the middle class. This was a missed opportunity to do the right thing,” said Assembly Speaker Robin Vos.
Senate Majority Leader Scott Fitzgerald also expressed discontent, saying, “While I’m disappointed in the governor’s actions, I’m not surprised – this is the second income tax cut he’s vetoed as governor.”
The State Assembly planned to make its February 20 floor date its last of the 2019-2020 session. As of this writing, there has been no indication that will change. The State Senate is planning on holding its last floor session in March. It’s unclear if the State Senate will attempt to override the veto. A successful override would be extremely difficult. It would take 22 votes to successfully override a veto. The Republicans currently have 19 seats. It’s doubtful they could pick up three Democratic votes.
Since the start of the year, a number of legislators have stated they will not be seeking reelection to their current positions. As of this writing, twelve legislators have announced they will not seek reelection. Six of those are retiring. The other six are running for higher office.
The six retiring are as follows:
The six seeking higher office are as follows:
These twelve announcements signal significant turnover in the next legislative session. More announcements are likely to come before legislators begin filing for candidacy in April.
Putting Home Care First with the Power of One
2020 is still in its infancy, but this year will be historic for policy advocacy here in our nation's capital and around the country.
Big issues on the table concerning everything from immigration to health care and home health care and hospice services are an integral part of that debate. More and more Americans are choosing to receive care and services in the comfort of their own homes and to age in place. The home health care and hospice communities are struggling to meet the ever growing demand amidst nursing and caregiver shortages. For those of us in the Home Care and Hospice Party, our attention will be focused like a laser on solutions to the problems faced by the millions of Americans who provide and depend on quality health care in the home.
Here at the National Association for Home Care & Hospice (NAHC), advocacy never sleeps AND never has it been more important for individuals to exercise their constitutional right to participate in the democratic process through advocacy; especially when it concerns the ability to receive quality health care and hospice services in the home.
We need you to join us in our advocacy effort to put
"Home Care First" with the
Power of One!
Forward this email today to ONE friend, or colleague, and ask them to sign up as an advocate by clicking:HERE
If every person gets ONE other person to sign up, we will be more than 100K strong in just a week's time.
2020 is new and full of possibilities and you can play an integral role helping us to build our army, strengthen our voice and the heartbeat of the industry.
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