On April 16, 2021, CMS published a notice on the MLNConnects webpage announcing the passage of the Act to Prevent Across-the-Board Direct Spending Cuts, and for Other Purposes. The law, enacted on April 14, 2021 extends the suspension of the Medicare “sequester” through December 31, 2021.
In anticipation of the legislation’s passage, CMS announced on March 30, 2021 that it had instructed its Medicare Administrative Contractors (MACs) to hold Medicare Fee-For-Service claims with dates of service on or after April 1, 2021. With the passage of the bill, CMS further indicated that it has instructed its MACs to release any claims currently being held, and to reprocess any claims paid with the sequester applied. CMS indicated that no action is required on the part of health care providers and suppliers.
CMS Increases Medicare Payment for COVID-19 Vaccinations
By Brian S. Werfel, Esq.
On March 15, 2021, the Centers for Medicare and Medicaid Services (CMS) announced that it would be increasing the Medicare payment amount for administrations of the COVID-19 vaccines.
The original Medicare reimbursement rate depended, in part, on whether the vaccine being administered required a two-dose regimen (as is the case for the Pfizer-Biontech and Moderna vaccines), or a single dose (Johnson & Johnson vaccine). For vaccinations that require a two-dose regime, CMS initially paid: (1) $16.04 for the administration of the first dose and (2) $28.39 for the administration of the second dose. For vaccines that require only a single dose, Medicare paid $28.39 for the administration of that single dose.
Effective for vaccinations administered on or after March 15, 2021, CMS has increased these payments to $40 per administration. Thus, the total reimbursement for a vaccine requiring a single dose will be $40, while the total reimbursement for a vaccine requiring a two-dose regimen will be $80.
On October 8, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Fact Sheet setting forth the repayment terms for advances made under the Medicare Accelerated and Advance Payments Program (AAPP). These changes were mandated by the passage of the Continuing Appropriations Act, 2021 and Other Extensions Act, which was enacted on October 1, 2020.
On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program to provide relief to Medicare providers and suppliers that were experiencing cash flow disruptions as a result of the COVID-19 pandemic, and associated economic lockdowns. Under the AAPP, Medicare providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments. These advances are structured as “loans,” and are required to be repaid through the offset of future Medicare payments.
CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act. CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.
Under the pre-existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds. The program also called for a 100% offset until all advanced funds had been repaid.
Revised Payment Terms
Under the revised payment terms announced by CMS, providers and suppliers will not be subject to recoupment of their Medicare payments for a period of one year from the date they received their AAPP payment. Starting on the date that is one year from their receipt of the AAPP payment, repayment will be made out of the provider’s or supplier’s future Medicare payments. The schedule for such repayments will be as follows:
To the extent there remains an outstanding AAPP balance after that 17 month period (i.e., 29 months after the date the provider or supplier received its AAPP payment, the provider or supplier will receive a letter setting forth their remaining balance. The provider or supplier will have 30 days from the date of that letter to repay the AAPP balance in full. To the extent the AAPP balance is not repaid in full within that 30-day period, interest will begin to accrue on the unpaid balance at a rate of 4%, starting from the date of the letter.
Medicare providers and suppliers are also permitted to repay their accelerated or advance payments at any time by contacting their Medicare Administrative Contractor.
On August 25, 2020, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule with a comment period titled “Medicare and Medicaid Programs, Clinical Laboratory Improvement Amendments of 1988 (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.” The interim final rule sets forth a number of new requirements designed to limit the COVID-19 exposure and to prevent the spread of COVID-19 within nursing homes.
Specifically, the interim final rule requires skilled nursing and other long-term care facilities to test residents and staff for COVID-19. The frequency of such testing is based on the positivity rate in which the facility is located, and can require COVID-19 testing as frequently as twice per week. Regardless of the frequency of required COVID-19 tests, facilities must also screen all staff, residents, and persons entering the facility for the signs and symptoms of COVID-19.
These requirements extend to individuals that provide services to nursing homes under arrangements, including health care personnel rendering care to residents within the facility. In subsequent guidance, CMS clarified that these testing and screening requirements apply to EMS personnel and other health care providers that render care to residents within the facility. However, in that same guidance, CMS indicated that EMS personnel must be permitted to enter the facility provided that: (1) they are not subject to a work exclusion as a result of to an exposure to COVID-19 or (2) showing signs or symptoms of COVID-19 after being screened.” CMS further indicated that “EMS personnel do not need to be screened so they can attend to an emergency without delay.”
In plain terms, CMS has created an affirmative obligation on nursing homes to ensure that any individual that provides services under a contractual arrangement with the nursing home comply with these testing and screening requirements. CMS has expressly waived the screening requirements for EMS personnel responding to medical emergencies at a nursing home. However, CMS has not specifically addressed the testing and screening requirements applicable to EMS personnel responding to nursing homes in non-emergency situations.
The A.A.A. is aware that a handful of State Health Agencies have issued their own guidance on this issue. The A.A.A. is also aware that individual nursing homes have started to require proof that EMS personnel have been tested for COVID-19 prior to allowing these individuals to enter the nursing home in a non-emergency situation.
EMS agencies may already be subject to state and local testing mandates. EMS agencies may also have their own internal policies that require employees to be periodically tested for COVID-19. As a result, there exists the potential for conflict where these existing testing policies conflict with the testing requirements of your local nursing homes.
The A.A.A. has been engaged in an ongoing conversation with CMS on these issues since the issuance of the interim final rule in August. As part of that conversation, the A.A.A. pushed for the exclusion of EMS personnel from the screening requirement when responding to medical emergencies, which was included in the recent CMS guidance document. The A.A.A. also continues to push for additional funding for COVID-19 testing for EMS agencies. CMS has recognized that the frequent testing of health care workers is essential to reducing the spread of the novel coronavirus. CMS has allocated funding for these purposes to other industries, including hospitals and nursing homes. As front-line health care workers, EMS agencies should have similar access to testing funds. The A.A.A. will continue to push for funding equity for the EMS industry.
In the interim, we strongly encourage our members to work with their state associations and other stakeholders to advocate for reasonable rules related to testing on the state and local levels. To the extent the applicable state or local agency has determined the appropriate frequency for the testing of EMS personnel responding to medical emergencies, those rules should also apply to EMS personnel responding to scheduled transports and other non-emergencies that start or end at a nursing home. Requiring more frequent testing in these situations would impose an undue burden on EMS agencies that provide these services. More frequent testing may also prove counterproductive, as it may discourage EMS agencies that cannot meet these higher requirements from responding in these situations. We also encourage our members to continue to push for state and local funding for the testing of their employees.
On September 22, 2020, the U.S. House of Representatives approved a continuing resolution to keep the government funded through December 11, 2020. Under current law, government funding is set to expire at midnight on September 30, 2020.
The House resolution is a stopgap measure that would maintain funding for most government programs at their current Fiscal Year 2020 levels. However, the Continuing Resolution omits $30 billion in agricultural aid sought by the Trump Administration and Senate Republicans. As of last week, it appeared that a compromise had been struck between the Administration and Speaker Pelosi under which the agricultural aid would be tied to the extension of special food benefits to recipients of free or reduced-price school lunches authorized by the Families First Coronavirus Response Act. The Continuing Resolution also does not include new spending on economic aid for those impacted by the coronavirus.
The Continuing Resolution will now go to the U.S. Senate for consideration.
Impact on Repayment of Medicare Accelerated and Advance Payments
In response to the COVID-19 pandemic, CMS announced that it would be opening the Medicare Accelerated and Advance Payment Program (AAPP) to all health care providers and suppliers that were impacted financially by the pandemic. Under the AAPP, Medicare-enrolled providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments. These advances were structured as “loans,” and were required to be repaid through the offset of future Medicare payments. CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act. CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.
Under the existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds. The program also called for a 100% offset until all advanced funds had been repaid.
The American Ambulance Association, the American Hospital Association, the Association of American Medical Colleges, and numerous other advocacy groups have advocated that the AAPP be revised to give health care providers and suppliers greater flexibility to repay the advanced funds. The AAA and others argued that these changes were necessary to avoid a financial crisis when CMS began offsetting Medicare payments to repay the advanced funds. A copy of the AAA’s letter to CMS Administrator Seema Verma can be viewed by clicking here.
In the Continuing Resolution, the House addressed this issue by making the following changes to the AAPP:
The Continuing Resolution would require the HHS Secretary to post within 2 weeks of enactment (and updated every 2 weeks thereafter) the following information related to the AAPP on the CMS website:
HHS would also be required to post periodic reports, starting in July 2021 and every six months thereafter until all AAPP amounts have been repaid, that contain the following:
The Senate will most likely approve the House CR before the September 30, 2020 deadline.
Section 1834(l)(3)(B) of the Social Security Act mandates that the Medicare Ambulance Fee Schedule be updated each year to reflect inflation. This update is referred to as the “Ambulance Inflation Factor” or “AIF”.
The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year. Starting in calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP). The MFP reduction may result in a negative AIF for any calendar year. The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.
For the 12-month period ending in June 2020, the federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U has increased by 0.646%.
Cautionary Note Regarding CPI-U. Members should be advised that the BLS’ calculations of the CPI-U are preliminary, and may be subject to later adjustment. Therefore, it is possible that these numbers may change.
CMS has yet to release its estimate for the MFP for calendar year 2021. Since its inception, this number has fluctuated between 0.3% and 1.2%. For calendar year 2020, the MFP was 0.7%. Under normal circumstances, it would be reasonable to expect the 2021 MFP to be within a percentage point or two of the 2020 MFP. However, the economic impact of the COVID-19 pandemic makes predictions on the MFP difficult at this point.
Accordingly, the AAA is not in a position to confidently project the 2021 Ambulance Inflation Factor at this point in time. However, the relative low increase in the CPI-U strongly suggests that the 2021 Ambulance Inflation Factor will be significantly lower than last year’s increase of 0.9%.
The AAA will notify members once CMS issues a transmittal setting forth the official 2021 Ambulance Inflation Factor.
American Ambulance Association Medicare Consultant Brian Werfel, Esq provides a brief update on the HHS COVID-19 Provider Relief Fund.
The Department of Health and Human Services (HHS) recently announced that it would be extending the deadline for health care providers to apply to receive general distribution funding from the HHS Provider Relief Fund. The deadline to apply for these funds was previously June 3, 2020.
On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. An additional $75 billion was allocated as part of the Paycheck Protection Program and Health Care Enhancement Act, bringing the total “Provider Relief Fund” up to $175 billion. This $175 billion will be distributed to health care providers and suppliers to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.
HHS ultimately elected to allocate these funds through a $50 billion “general allocation,” and multiple smaller “targeted allocations.”
Under its general allocation program, HHS intended to provide health care providers with funds roughly equal to 2% of the provider’s 2018 “net patient revenue,” i.e., the provider’s total revenues from patient care minus provisions for bad debt, contractual write-offs, and certain other adjustments. This general allocation was made in two tranches, with the first tranche being distributed to all providers in mid-April. This first tranche was made based on provider’s 2019 Medicare revenues. As a result, any provider that received payments from the Medicare Fee-for-Service Program in 2019 automatically received an initial relief payment. However, HHS required providers to submit an application to receive relief funding as part of the second tranche. The deadline for applying for the second tranche of relief funding was June 3, 2020.
Scope of New Extension
HHS indicated that the new extension is limited to health care providers that missed the June 3, 2020 deadline to apply for the second tranche of relief funding. The extension also applies to providers that were ineligible for the first tranche of relief funding due to a recent change of ownership. The specific situations that HHS indicated would meet the requirements for the extension include:
Health care providers that meet one of the requirements listed above will have until August 28, 2020 to submit an application for additional relief funds. This deadline aligns with the extended deadline for other eligible Phase 2 providers, such as Medicaid, Medicaid Managed Care, CHIP, and dental providers.
Applications should be submitted through the CARES Provider Relief Fund webpage, which can be found at: https://cares.linkhealth.com/#/.
On July 7, 2020, CMS updated its Coronavirus Disease 2019 (COVID-19) Provider Burden Relief Frequently Asked Questions (FAQs). As part of this update, CMS indicated that it would resume several program integrity functions, starting on August 3, 2020. This includes pre-payment and post-payment medical reviews by its Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), and the Recovery Audit Contractors (RACs). This also includes the resumption of the Prior Authorization Model for scheduled, repetitive non-emergency ambulance transports. These programs had been suspended by CMS in March in response to the COVID-19 pandemic.
Resumption of Medicare Fee-For-Service Medical Reviews
CMS suspended most Medicare FFS medical reviews on March 30, 2020. This included pre-payment medical reviews conducted by its MACs under the Targeted Probe and Educate program, as well as post-payment reviews by its MACs, the SMRC, and the RACs. CMS indicated that, given the importance of medical review activities to CMS’ program integrity efforts, it expects to discontinue its “enforcement discretion” beginning on August 3, 2020.
CMS indicated that providers selected for review should discuss any COVID-related hardships that might affect the provider’s ability to respond to the audit in a timely fashion with their contractor.
CMS further indicated that its contractors will be required to consider any waivers and flexibilities in place at the time of the dates of service of claims selected for future review.
Resumption of Prior Authorization Model
Under the Repetitive, Scheduled, Non-Emergent Ambulance Transport Prior Authorization Model, ground ambulance providers in affected states are required to seek and obtain prior authorization for the transportation of repetitive patients beyond the third round-trip in a 30-day period. The Prior Authorization Model is currently in place in Delaware, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, West Virginia, and the District of Columbia.
On March 29, 2020, CMS suspended certain claims processing requirements under the Prior Authorization Model. During this “pause,” claims for repetitive, scheduled, non-emergency transports were not be stopped for pre-payment review to the extent prior authorization had not been requested prior to the fourth round trip in a 30-day period. However, CMS continued to permit ambulance providers to submit prior authorization requests to their MACs.
CMS indicated that full model operations and pre-payment review would resume for repetitive, scheduled non-emergent ambulance transportation submitted in the model states on or after August 3, 2020. CMS stated that the MACs will be required to conduct postpayment review on claims that were subject to the model, and which were submitted and paid during the pause. CMS further indicated that it would work with the affected providers to develop a schedule for postpayment reviews that does not significantly increase the burden on providers.
CMS stated that claims that received a provision affirmation prior authorization review decision, and which were submitted with an affirmed Unique Tracking Number (UTN) will continue to be excluded from most future medical review.
On July 7, 2020, the Internal Revenue Service published a series of Frequently Asked Questions that address the taxation of payments to health care providers under the HHS Provider Relief Fund.
As part of the Coronavirus Aid, Relief and Economic Security Act (CARES Act), Congress appropriated $100 billion to reimburse eligible health care providers for health care-related expenses and/or lost revenue attributable to the COVID-19 pandemic. The Paycheck Protection Program and Health Care Enhancement Act appropriated an additional $75 billion to the Provider Relief Fund.
The first FAQ addressed the issue of taxation for for-profit health care providers. Specifically, the IRS was asked whether a for-profit health care provider is required to include HHS Provider Relief Fund payments in its calculation of “gross income” under Section 61 of the Internal Revenue Code (Code), or whether such payments were excluded from gross income as “qualified disaster relief payments” under Section 139 of the Code.
The IRS indicated that payment from the Provider Relief Fund do not qualify as qualified disaster relief payments under Section 139 of the Code. As a result, these payments are includible in the gross income of the entity. The IRS further indicated that this holds true even for businesses organized as sole proprietorships.
The second FAQ addressed the issue of taxation for tax-exempt organizations. The IRS indicated that health care providers that are exempt from federal income taxation under Section 501(a) would normally not be subject to tax on payments from the Provider Relief Fund. Notwithstanding this general rule, the IRS indicated that the payment may be subject to tax under Section 511 of the Code to the extent the payment is used to reimburse the provider for expenses or lost revenue attributable to an unrelated trade or business as defined in Section 513 of the Code.
The IRS FAQ can be viewed in its entirety by clicking here. Members are advised to discuss the issue of potential taxation of any relief funding they received with their tax professionals.
On May 1, 2020, CMS updated its “COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing.” The full document can be viewed by clicking here.
In the updated FAQ, CMS answers three important questions related to ambulance vehicle and staffing requirements:
The Department of Health and Human Services recently updated its guidance on the disbursement of provider relief funds under the CARES Act for the testing and treatment of the uninsured. Previously, HHS indicated that this allocation was only available for the reimbursement of emergency and non-emergency ground ambulance transportation. However, in its most recent update, HHS has removed the restriction that limited participation to ground ambulance providers and suppliers. The new guidance indicates that the relief funds are now available for all emergency ambulance transportation and non-emergency patient transfers via ambulance.
Thus, it appears that air and water ambulance providers and suppliers are now eligible to receive funding for the treatment of COVID-19 patients.
Is there anything my air or water ambulance organization needs to do to claim reimbursement for treatment of uninsured COVID patients?
Yes. In order to be eligible for payments for the treatment of uninsured COVID patients, you must enroll as a participant in the program. Enrollment must be done through an online portal that can be accessed at: http://www.coviduninsuredclaim.hrsa.gov.
Once my organization enrolls, when can we start submitting claims for reimbursement for treatment of uninsured COVID patients?
HHS has indicated that it will begin to accept claims for reimbursement for treatment of the uninsured on May 6, 2020.
FUNDING FOR TREATMENT OF UNINSURED COVID PATIENTS IS SUBJECTED TO AVAILABLE FUNDING, AND IS THEREFORE ON A FIRST-COME, FIRST-SERVED BASIS. IT IS EXPECTED THAT THESE FUNDS WILL BE EXHAUSTED IN FAIRLY SHORT ORDER.
Updated April 24, 2020 at 9:40 pm | Register for AAA’s 4/27 webinar on this topic►
At 5 p.m. on Friday, April 24, 2020, the Department of Health and Human Services opened the online portal that health care providers and suppliers must use to submit their revenue information. This is a requirement to access the second $20 billion tranche of general allocation funding. Access the online portal►
In order to provide the required information, you will need the following information/documentation:
The portal will ask a series of questions to verify your identity and the identity of your organization. These include providing your TIN and the last six digits of the bank account to which the original tranche of relief funding was provided.
After completing the verification process, you will be asked to complete an attestation that you received the initial tranche of relief funding.
You will then be prompted to complete a short questionnaire that is used to apply for additional funding. The steps for completing that questionnaire are as follows:
AAA is aware of an issue that may affect governmental EMS organizations. Specifically, those governmental agencies that do not file federal tax returns may not be able to complete the final stage of the application, which asks you to upload a copy of your most recent tax return. The AAA has reached out to HHS to request guidance on how governmental organizations should complete the form. We will update our members as soon as we know anything different. Register for our May 4 COVID-19 Financial Resources for Governmental Providers webinar►
HHS indicated that it will allocate an undisclosed portion of the $29.6 billion in otherwise unallocated relief funding to reimburse healthcare providers and suppliers for COVID-related treatment of the uninsured. Please note that this allocation is only available for the reimbursement of emergency and non-emergency ground ambulance transports. Reimbursement will be available for COVID-related care furnished with dates of service on or after February 4, 2020. Payments will be made at the Medicare rates, subject to available funding. As a condition to receipt of funding, you must agree to accept HHS’ payment as payment-in-full, i.e., you may not balance bill the uninsured patient.
Yes. In order to be eligible for payments for the treatment of uninsured COVID patients, must enroll as a participant in the program. Enrollment must be done through an online portal that will open starting on April 27, 2020. Once open, the portal can be accessed at http://www.coviduninsuredclaim.hrsa.gov.
HHS has indicated that it will begin to accept claims for reimbursement for the treatment of the uninsured at some point in early May 2020.
FUNDING FOR TREATMENT OF UNINSURED COVID PATIENTS IS SUBJECTED TO AVAILABLE FUNDING, AND IS THEREFORE ON A FIRST-COME, FIRST-SERVED BASIS. IT IS EXPECTED THAT THESE FUNDS WILL BE EXHAUSTED IN FAIRLY SHORT ORDER.
The AAA strongly recommends that all members complete their enrollment form as soon as reasonably practicable, so that you are in a position to submit claims as soon as the claim submission window opens.
HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding
By Brian S. Werfel, Esq.
March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10. These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19. Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”
The Department of Health and Human Services (HHS) began the disbursement of the first $30 billion tranche of the CARES Act Provider Relief Funding on April 10, 2020, with full disbursement of this tranche being completed by April 17, 2020. The American Ambulance Association has issued a Frequently Asked Question that provides additional details on how the payments under this first tranche were calculated, as well as the terms and conditions that are applicable to this disbursement.
On April 22, 2020, HHS announced its plans for the disbursement of the remaining $70 billion in CARES Act Provider Relief Funding. These monies will be distributed using four broad categories:
Upcoming Important Dates
To participate in these future funding tranches, AAA Members will need to keep the following dates in mind: