- UPDATED – COVID-19: An Advocates Guide to Beneficiary Related Medicare Changes
- Special Report – Who’s Providing Care to Nursing Home Residents?
- Research Underscores Disproportionate Impact of COVID-19
- WHO Releases New Policy Brief: “Preventing and Managing COVID-19 Across Long-Term Care Services”
Updated July 2020
The global COVID-19 crisis has led to many changes in health care rules, including in the Medicare program. Most of the Medicare changes are slated to be temporary, but advocates will need to watch which provisions do and do not remain after the crisis. While a many of the changes affect health care providers, including payment and waivers of certain requirements, our Advocates Guide focuses on Medicare COVID changes that relate to beneficiaries and their access to covered care. Note: This Advocates Guide describes, but does not analyze or critique these changes.
TABLE OF CONTENTS
- OVERVIEW OF MEDICARE-RELATED COVID CHANGES
- SPECIFIC MEDICARE CHANGES
- MEDICARE PART A
- Acute Care Hospitals
- Critical Access Hospitals (CAH)
- Long-Term Care Hospitals (LTCHs)
- Extended Neoplastic Disease Care Hospitals (ENDCH)
- Skilled Nursing Facilities (SNFs)
- Inpatient Rehabilitation Facilities (IRFs, also known as Inpatient Rehab. Hospitals/IRHs)
- Psychiatric Hospitals
- All Hospitals
- Home Health
- MEDICARE PART B
- COVID-19 Testing
- COVID-19 Vaccine
- Hospital Outpatient Services Furnished at Home
- Therapy Services (Physical Therapy/PT, Occupational Therapy/OT, Speech Language Pathology/SLP)
- Ambulance Transport
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
- Opioid Treatment Programs
- Remote Physiologic Monitoring (RPM)
- Home Infusion Services
- MEDICARE PARTS C and D
- COVID-19 Related Updates to Medicare Parts C and D Enrollment
- Medicare Advantage (MA)
- Part D Plans (including MA-PDs)/Prescription Refills
- COVID-19 Related Updates to Medicare Part A and B Enrollment
- Notice Delivery in Institutions
- Medicare Appeals
- Information Regarding Providers
- Non-Discrimination re: Provision of Health Services
- Non-Essential Care
- State Medicaid Issues for Dual Eligibles
- Oral Health
- Disparities in COVID-19 Infections
- MEDICARE PART A
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Under the federal Nursing Home Reform Law (1987), nurse aides may not work for more than four months unless they are trained in a training program of at least 75 hours and determined to be competent. On March 20, 2020, as part of a long list of waivers and flexibilities granted to nursing facilities, CMS waived the four-month rule, but not the competency requirement.
Shortly after Centers for Medicare & Medicaid Services (CMS) announced the waivers in March, the American Health Care Association (AHCA), the trade association of mainly for-profit nursing facilities, reported that it had been advocating for such a waiver. Simultaneously, AHCA announced that it had developed a free eight-hour on-line training course for a “temporary position intended to address the current state of emergency.”
Other states authorize other types of waivers of nurse aide training requirements. Florida created new temporary Personal Care Attendant program “to help long-term care facilities fill staffing shortages. The program provides an 8-hour training on assisting with direct care so that personal care attendants can temporarily perform additional duties.”
Other states recognize that CMS has waived the 75-hour training requirements but impose different requirements. California allows a nurse assistant who is enrolled in an approved certification training program to “continue to be employed throughout the declared emergency . . . but is encouraged to complete the program as training programs resume.” Colorado waives the nurse aide training requirements, but not the competency requirement, during the emergency, and authorizes facilities to use “uncertified staff” to perform “direct health care tasks.”
On https://educate.ahcancal.org/tna, the American Health Care Association identifies additional states as allowing ACHA’s eight-hour training course. The Center was unable to find material about those states.
Questions and Discussion
With staff infected by COVID-19 and unable to work, new staff members are undoubtedly needed. But there are many questions about these workers that need answers.
How prevalent is the use of these temporary aides? Is CMS tracking who they are, how many there are, which facilities they are working in, what tasks they are performing and how well?
What happens to temporary aides after the pandemic ends? Some states answer the question, but most are silent.
- Will they be fired?
- Illinois prohibits temporary nurse aides from taking the certified nurse assistant competency exam and says they “will not be employed as an aide after the pandemic emergency.”
- Will they be grandfathered in as permanent certified nurse assistants?
- Pennsylvania providers asked for waiver of nurse aide training and competency evaluation requirements for staff who “worked in this capacity for at least one month during the emergency” and for waiver of the training requirement for workers who worked less than one month during the emergency.
- Will they be required to take the state’s mandated aide training course and pass the state’s competency evaluation test?
- Georgia will allow a period of time, after the emergency is lifted, for temporary aides to complete additional training and pass the state competency test.
- Kansas will require temporary aides to complete the state’s 90-hour training course and to pass the state exam to be certified as a CNA.
Particularly since nurse aides provide most of the direct care to residents, the qualifications of nurse aides and other staff members providing care to residents are critically important. The country cannot return to the time before the 1987 Nursing Home Reform Law when half the states did not require that aides get training and demonstrate competency before providing care to residents.
To read the full report, Who’s Providing Care for Nursing Home Residents? Nurse Aide Training Requirements during the Coronavirus Pandemic, please go to: https://medicareadvocacy.org/wp-content/uploads/2020/07/Report-Nurse-Aide-Training.pdf
 42 U.S.C. §§1395i -3(b)(5), 1396r(b)(5), Medicare and Medicaid, respectively; 42 C.F.R. §§483.35(d)(1)(i), (ii), 483.35(c).
 CMS, “Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19” (Mar. 28, 2020), https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf.
 AHCA, Temporary Nurse Aide Training & Competency Checklist https://educate.ahcancal.org/products/temporary-nurse-aide.
 Division of Public Health and Delaware Emergency Management Agency Orders and Waivers and Centers for Medicare and Medicaid Services Blanket Waivers Long Term Care Facilities, https://coronavirus.delaware.gov/wp-content/uploads/sites/177/2020/04/Healthcare-Waivers-4_9_2020.pdf.
 Georgia Department of Community Health, “Healthcare Facility Regulation Division COVID-19 Information; Partnership with GHCA on Nurse Aide Training,” with links to the COVID-19 Temporary Nurse Aide Training Program (effective Mar. 20, 2020), https://dch.georgia.gov/healthcare-facility-regulation-division-covid-19-information.
Illinois Department of Public Health Temporary Nursing Assistant (TNA) Training Program, https://www.ihca.com/Files/COMM-COVID-19/TNA%20Training%20Program%20Instructions.pdf.
 Indiana State Department of Health, “Sixth Emergency Order Granting Temporary Blanket Waivers for Comprehensive Care Facilities” (issued Apr. 18, 2020, effective Mar. 6, 2020), https://www.coronavirus.in.gov/files/AA%20-%20CCF%20Waiver%20Order%20%236%2020200418%20Temp%20NAs%20Fjnal%20Signed.pdf , https://www.coronavirus.in.gov/2499.htm.
 Iowa Department of Inspections and Appeals, COVID-19, Frequently Asked Questions for Health Facilities, p. 9, Question CNA4 (updated Jun .1, 2020), https://dia.iowa.gov/sites/default/files/documents/2020/06/dia-hfd-covid-19-faqs.pdf.
 Kansas Department for Aging and Disability Services, “COVID-19 Temporary Nurse Aide Training Program” (effective Apr. 17, 2020), https://www.coronavirus.kdheks.gov/DocumentCenter/View/968/Temporary-Aide-Guidance–PDF—4-17-2020.
 The State of Florida Issues COVID-19 Updates (Apr. 19, 2020), www.floridahealth.gov/newsroom/2020/04/042020-1845-covid19.pr.html.
 California Department of Public Health, “Suspension of Professional Certification Requirements for Certified Nurse Assistants (CNAs),” AFL 20-35 (Apr. 5, 2020), All Facilities Letter, https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-35.aspx (waiving specified statutory and regulatory requirements, including training requirements for initial certification, at HSC section 1337.5(b)(2)-(3)); California Department of Public Health, “Suspension of Specified Regulatory Requirements for Nurse Assistant Training Programs (NATPs),” AFL 20-40 (Apr. 14, 2020), https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-40.aspx.
 Colorado Department of Health Care Policy & Financing, ‘Certified Nursing Assistant, Nursing Facilities, Training Requirements, COVID-19, Coronavirus,” Operational memo number: HCPF OM 20-038 (Apr. 8, 2020, effective Mar. 1, 2020), https://www.colorado.gov/pacific/sites/default/files/HCPF%20OM%2020-038%20Temporary%20Training%20and%20Certification%20of%20Nurse%20Aides%20%281%29.pdf.
 June 8, 2020 letter to Secretary of the Pennsylvania Department of Education from LeadingAgePA, Healthcare Council of Western Pennsylvania, Pennsylvania Health Care Association, and Pennsylvania Coalition of Affiliated Healthcare & Living Communities, https://www.leadingagepa.org/Portals/0/Documents/Letter%20to%20Sec.%20Rivera%206-8-2020%20(02).pdf?ver=2020-06-08-213637-723.
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The Center for Medicare Advocacy continues to bring attention to the disproportionate impact of COVID-19 on minority and immigrant households. Recent research includes:
Center on Budget and Policy Priorities:
- More Relief Needed to Alleviate Hardship: Households Struggle to Afford Food, Pay Rent, Emerging Data Show
“The economic fallout from the pandemic began in earnest in the latter half of March. Since then, job losses have been larger than at any time during the Great Recession and hardship has hit extremely high levels. The health impacts of the virus, job losses, and serious measures of deprivation — difficulty affording food and being behind on rent — are widespread, affecting tens of millions of people.
But the impacts are not affecting all groups evenly, with the crisis hitting Black, Latino, Indigenous, and immigrant households particularly hard. Inequities, driven by racism and discrimination, in education, housing, employment, and health care, among other factors, mean that workers in these communities disproportionately work in low-paid jobs that have been heavily affected by the crisis, households have fewer assets to fall back on in hard times, and individuals are more likely to have underlying health conditions.”
Kaiser Family Foundation:
- Growing COVID-19 Hotspots in the U.S. South and West will Likely Widen Disparities for People of Color
“The large number of people of color living in COVID-19 hotspots coupled with the already disproportionate impact for people of color will likely lead to further growth in disparities as the outbreak shifts to the South and West. Potential growing impacts for the large shares of Hispanic and Asian people living in these areas heighten the importance of providing information and services in linguistically and culturally appropriate ways and addressing potential fears that could make those who have an immigrant family member hesitant to access services. Prior to the pandemic, growing research showed that many immigrant families were increasingly fearful of accessing services, including health care services, due to recent immigration policy changes. Rising cases will likely compound the major challenges AIAN people already are facing due to the pandemic and widen disproportionate impacts for Black individuals, as these groups are at increased risk of experiencing serious illness if they contract the virus due to high rates of underlying health conditions. People of color also are at increased risk of exposure to the virus, face increased barriers to testing and treatment, and are more vulnerable to financial challenges due to the pandemic due to social and economic circumstances.”
- In Medicare, Black and Hispanic Individuals Account for Disproportionate Share of COVID-19 Cases and Hospitalizations
It is essential to continue to shine a light on research like the works cited above to ensure that it is central to policy proposals developed in response to the pandemic.
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Just shy of seven months since the World Health Organization (WHO) first received reports of a cluster of cases of “pneumonia of an unknown cause” in China, the WHO has issued a policy brief about preventing and managing COVID-19 across long-term care services. The COVID-19 pandemic has infected more than 13 million people around the world and claimed the lives of nearly 600,000. More than 40 percent of those deaths have been linked to long-term care facilities. In some high-income countries, that figure balloons to 80 percent.
The WHO brief outlines 11 policy objectives and key action points aimed to prevent and mitigate the impact of COVID-19 across the long-term care spectrum, including home and community-based care. Additionally, the brief suggests ways to transform health and long-term care services to increase the likelihood that they are integrated into the continuum of care.
Geared toward policy makers and authorities involved in the pandemic, these eleven recommendations are built upon evidence-based measures taken to prevent, prepare and respond to the pandemic:
- Include long-term care in all phases of the national response to the COVID-19 pandemic.
- Mobilize adequate funding for long-term care to respond to and recover from the COVID-19 pandemic.
- Ensure effective monitoring and evaluation of the impact of COVID-19 on long-term care and ensure efficient information channeling between health and long-term care systems to optimize responses.
- Secure staff and resources, including adequate health workforce and health products, to respond to the COVID-19 pandemic and delivery quality long-term care services.
- Ensure the continuum and continuity of essential services for people receiving long-term care, including promotion, prevention, treatment, rehabilitation and palliation.
- Ensure that infection prevention and control standards are implemented and adhered to in all long-term care settings to prevent and safely manage COVID-19 cases.
- Prioritize testing, contact tracing and monitoring of the spread of COVID-19 among people receiving and providing long-term care services.
- Provide support for family and volunteer caregivers.
- Prioritize the psychosocial well-being of people receiving and providing long-term care services.
- Ensure a smooth transition to the recovery phase.
- Initiate steps for transformation of health and long-term care systems to appropriately integrate and ensure continuous, effective governance of long-term care services.
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