COVID-19 Policy Updates

This page will continue to be updated as new guidance and information becomes available.

General | Substance Use Disorder Treatment | Centers for Medicare & Medicaid Services | Additional Info

General Updates

Enhanced Portal allows Medicaid/CHIP providers to apply for a Provider Relief Fund payment, regardless of network affiliation or payer contract. Deadline to apply is July 20, 2020. Download instructions and application. Removing Barriers to Mental Health Care: On May 12 The Joint Commission announced support for the removal of any barriers that inhibit clinicians and health care staff from accessing mental health care services, including eliminating policies that reinforce stigma and fear about the professional consequences of seeking mental health treatment.

Telehealth Guidance

• The Center for Connected Health Policy maintains a state-by-state list of actions taken to remove policy barriers to the use of telehealth.
• HHS waived penalties for HIPAA violations against providers serving patients through technologies like Facetime or Skype during the COVID-19 public health emergency.
• For the latest from CMS, please see below.
• The Federal Communications Commission’s (FCC) COVID-19 Telehealth Program is providing funding for telehealth technology and equipment during the COVID-19 crisis for eligible nonprofit healthcare providers.
• CMS toolkit for states to help accelerate adoption of broader telehealth coverage policies in the Medicaid and Children’s Health Insurance Programs (CHIP).

Licensure/Credentialing Updates & Guidance

• The American Association of Nurse Practitioners provides this list of states who have temporarily suspended practice agreement requirements as a part of their emergency response.
• The National Council of State Board of Nursing provides state-by state lists applicable to nurses on:
  • Emergency actions taken by states
  • NRB exceptions for inactive and retired licenses.
• ANCC has issued the following regarding certification:
  • Expiration date extension to July 31, 2020 for those who have not yet applied for recertification and have a recertification date from March 1–July 1, 2020
  • Clinicians who have already submitted renewal documents will continue to be reviewed. Clinicians who want to renew can continue to do so.
  • ABSNC approved ANCC’s application to deliver its examinations via remote proctoring (LRP). Those who had a test date will be able reschedule. All eligible clinicians are provided a 120-day testing window.
• The Joint Commission issued information on requirements for granting privileges during a disaster once an organization has enacted their Emergency Operations Plan:
  • Licensed Independent Practitioners currently credentialed and privileged by the organization can provide the same services via a telehealth link to patients without any additional credentialing or privileging.
  • For organizations granting disaster privileges to volunteer licensed practitioners, The Joint Commission has these requirements.
• The declaration of a state of emergency allows HHS to waive certain federal licensing requirements for nurses and doctors in order to expand access to services. CMS offered this guidance for health care providers.
• For the latest from CMS, please see below.

Safety

• On May 7, the FDA issued an alert to advise health care providers that certain filtering facepiece respirators from China may not provide adequate respiratory protection.
• On May 7 SAMHSA certified that mental health and substance use disorder treatment are essential medical services and may require personal protective equipment.
• On April 23, The Joint Commission recommended the implementation of universal masking for healthcare settings in communities where coronavirus is occurring in order to protect staff and patients from being infected by asymptomatic and presymptomatic individuals.
• On April 13, the Centers for Disease Control issued updated guidance for infection control for patients with suspected or confirmed coronavirus, recommending that health care facilities implement source control for everyone entering the facility, regardless of symptoms.
• In response to shortages of N95 respirators, OSHA announced on April 3 that health care and other employers may consider alternatives to standard uses of PPE. Employers, as long as they adhere to CDC guidance, will not be cited for violating respiratory protection rules if they take measures such as reusing N95s.
• On April 3, the American Nurses Association, along with AMA and AHA, issued a statement to the public on the use of cloth masks.
• The Joint Commission issued a statement on March 31 supporting the use of personal face masks provided from home during the coronavirus pandemic when other personal protective equipment is not available.
• Specifically referring to the coronavirus pandemic, OSHA noted it is illegal to retaliate against workers who report unsafe conditions on the job and that workers have specific rights to file whistleblower complaints if they believe they are experiencing retaliation for reporting unsafe working conditions. Whistleblowers can call 1-800-321-OSHA.

On March 27 the CARES Act was signed into law. Relevant provisions include:

• Funding to increase the availability of personal protective equipment and other medical supplies.
• Support of expanded testing across the country
• Direct aid to hospitals and community health centers on the front lines
• Reauthorizes Title VIII Nursing Workforce Development Programs.
• Authorizes Advanced Practice Nurses (NPs and CNSs) to certify home health care for their patients
• Childcare assistance for essential workers (determined at the state level)
• SAMHSA Emergency Allocation: Funding for community behavioral health organizations, suicide prevention programs, SAMHSA programs generally, and for tribes.
• Provides liability protections for health care providers who provide volunteer medical services during the COVID-19 public health emergency.
• May 1 update: HHS is processing payments from the Provider Relief Fund to hospitals with large numbers of COVID-19 inpatient admissions through April 10, 2020, and to rural providers in support of the national response to COVID-19.
• June 11 update: Providers can sign an attestation, accept or return the funds, agree to terms and conditions, submit revenue information, and request reimbursement. (Only providers with complete submissions received prior to the June 3 deadline will be considered for an additional General Distribution payment.)

The FDA released guidance regarding drugs subject to REMS with laboratory testing (or imaging) requirements.

• This includes Clozapine:
  • Providers prescribing and/or dispensing these drugs should consider if there are compelling reasons not to complete or delay lab tests and use their best judgement in weighing the risks/benefits of continuing treatment without laboratory testing.
  • The provider should communicate this judgement of risks/benefits to patients.
  • The FDA does not intend to take action against providers for the duration of the public health emergency for failing to adhere to REMS requirements for certain laboratory testing.

Substance Use Disorder Treatment

SAMHSA has expedited its process to release emergency grants to strengthen access to treatments for substance use disorders and serious mental illnesses.

Updated April 21: The Drug Enforcement Administration and SAMHSA released guidance that:

• In addition to the previous stipulation that authorized prescribers may use telehealth in lieu of an in-person physical examination, new guidelines establish that telephone voice examinations are also acceptable for prescribing buprenorphine.
• The practitioner can prescribe buprenorphine to new and existing patients via telehealth (including phone).
• The practitioner can prescribe methadone to existing patients via telehealth (including phone). An in-person medical evaluation is still required for new patients treated with methadone.
• The practitioner must use their best judgment to determine that an adequate telephone examination can be conducted.
• The prescription also must otherwise be consistent with the practitioner’s obligation under regulations to only prescribe controlled substances for a legitimate medical purpose while acting in the usual course of professional practice.
• With appropriate licensing and registration APRNs can prescribe MAT medication in the absence of physician supervision.

SAMHSA previously relaxed regulations that require providers to obtain written patient consent for disclosure of substance use disorder records if the provider determines that a medical emergency exists.

SAMHSA expanded guidance allowing states to request blanket exceptions for stable patients to receive 28 days of take-home medication for the treatment of opioid use disorder.

Centers for Medicare & Medicaid Services

On April 30, CMS released a range of changes to support access to care:

• Medicare will now cover audio-only phone services. Previously Medicare recipients could only receive behavioral health services via videoconferencing. (See designated codes). CMS is also increasing payments for these telephone visits to match payments for similar office and outpatient visits
• COVID-19 tests may be ordered by any healthcare professional authorized to do so under state law.
• Inpatient psychiatric facilities can admit more patients without facing reduced teaching status payments
• Community Mental Health Centers can temporarily offer partial hospitalization and other mental health services to clients in the safety of their homes.

CMS and the Assistant Secretary of Preparedness and Response (ASPR) released a new toolkit to help state and local healthcare decision makers maximize workforce flexibilities in their communities.On April 19, CMS released its first in a series of recommendations for re-opening health care facilities in areas with low incidence of COVID-19. Maximum use of telehealth is “strongly encouraged” by CMS; these recommendations are for care that cannot be accomplished virtually.The guidance is for states or localities who meet the April 16 Gating Criteria and includes the following recommendations for Non-COVID-19 in-person care:

• Offer clinically appropriate care when the organization/state/locality has the resources to both provide this care and quickly respond to any possible COVID-19 surge.
• Prioritize surgical/procedural care and high-complexity chronic disease management. Certain preventative services may also be necessary.
• Ensure adequate resources to meet needs across phases of care without jeapordizing surge capacity. This includes PPE, healthy workforce, facilities, supplies, testing capacity, and post-acute care.
• Provide care in separate area from where COVID-19 care is occurring and with minimal crossover (separate building, for example).
• Establish a plan for thorough cleaning and disinfection prior to using spaces or facilities for patients with non-COVID-19 care needs.
• Routinely screen patients and staff for symptoms of COVID-19 (including temperature checks).
• Do not rotate staff working in these non-COVID care areas into COVID-19 care zones.
• Providers and staff should wear surgical facemasks at all times.
• Patients should wear a cloth face covering that can be bought or made at home if they do not already possess surgical masks.
• Facilitate social distancing with controls such as minimizing time in waiting areas, spacing chairs at least 6 feet apart, and maintaining low patient volumes.
• Prohibit visitors unless they are necessary for an aspect of patient care, in which case they should be screened in the same way as patients.
• When adequate testing capability is established, screen patients should with laboratory testing before care, and regularly screen staff working in these facilities by laboratory test.

On April 9, CMS updated its blanket waivers in place, including:

• To allow hospitals (Psychiatric Hospitals, and Critical Access Hospitals) to use practitioners to the fullest extent possible, CMS is waiving requirements that require Medicare patients be under the care of a physician.
• APRNs and physician assistants may perform some medical exams on Medicare patients at skilled nursing facilities.
• To increase flexibility for staffing mixes, the requirement that an APRN, physician assistant, or certified nurse-midwife be available to provide patient care services at least 50% of the time at Rural Health Clinics and FQHCs is waived. The requirement that a physician, APRN, physician assistant, certified nurse-midwife, clinical social worker, or clinical psychologist to be available to furnish patient care services at all times the clinic or center operates still stands.

On April 8 CMS posted updated guidance for:

• Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs): FAQs, Considerations for Patient Triage, Placement, Limits to Visitation and Availability of 1135 waivers
• Guidance for Infection Control and Prevention of Coronavirus Disease (COVID-19) in Outpatient Settings: FAQs and Considerations
• Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) and Psychiatric Residential Treatment Facilities (PRTFs)

On April 7 CMS issued a letter to clinicians that provides an overview of actions taken thus far and includes the following actions to help providers experiencing increased demand and surge in patients:

• CMS will provide accelerated payments to requesting providers who submit a request to the appropriate Medicare Administrative Contractor (MAC) and meet specific criteria
• MACs processing accelerated/advance payment requests will prioritize those states that were hit the hardest
• Waiving requirements that nursing staff develop and keep current a nursing care plan for each patient
• Requirements that the hospital have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present are waived

On April 2, CMS updated its blanket waivers in place, including:

• Waived the requirement for to provide detailed information regarding discharge planning for hospitals, psychiatric hospitals, and CAHs.
• Written policies and procedures for staff to use when evaluating emergencies are not required for surge facilities.
• CMS is waiving the requirements that the nursing staff develop and keep current a nursing care plan for each patient, and that the hospital have policies and procedures in place establishing which outpatient departments are not required to have a registered nurse present.
• Minimum personnel qualifications for clinical nurse specialists and nurse practitioners are waived to allow critical access hospitals to employ individuals in these roles who meet state licensure requirements and provide maximum staffing flexibility.
• CMS is deferring staff licensure, certification, or registration to state law
• Hospitals, psychiatric hospitals, and CAHs may screen patients at a location offsite from the hospital’s campus to prevent the spread of COVID-19

CMS issued new guidance and information on March 31 around measures to help the health care system meet needs during the public health emergency. Updates applicable to psychiatric-mental health nurses include:

To Increase Hospital Capacity:

• Non-hospital buildings approved by the state can temporarily be used for care and quarantine sites.
• Hospitals and other entities can perform COVID-19 tests in homes and other community-based settings.
• When other transportation is not medically appropriate, ambulances can transport patients to a wider range of care locations.
• Hospitals can bill for services provided off-site and new rules ensure that patients can be screened at alternate treatment and testing sites not subject to EMTALA.
  • This allows psychiatric hospitals to screen patients elsewhere to prevent the spread of COVID-19.

CMS previously recommended the delay of adult elective surgeries, and non-essential medical, surgical, and dental procedures in order to preserve personal protective equipment, beds, and ventilators. Electroconvulsive Therapy (ECT) is an essential procedure, according to the American Psychiatric Association.

In March, acute care hospitals with excluded distinct part inpatient psychiatric units were granted a waiver to, if needed, relocate inpatients from the psychiatric unit to an acute care unit so long as the beds are appropriate for psychiatric patients and the staff and environment are conducive to safe care.

To Expand the Health Care Workforce:

• Barriers to hiring nurses and other clinicians locally and from other states have been removed for hospitals and health care systems.
  • Clinicians can perform the functions they are qualified and licensed for while waiting on completion of federal paperwork requirements.
  • Requirements that out-of-state providers be licensed in the state where they are providing services when they are licensed in another state are waived for Medicare and Medicaid.
• Advanced Practice Nurses can practice to the fullest extent possible in accordance with a state’s emergency preparedness or pandemic plan.
  • If permitted under state law, they can perform services such as order tests and medications that may have previously required a physician’s order.
• Hospitals can provide benefits and support to health care staff, such as meals, laundry service, or child care while the staff are at the hospital doing work that benefits the hospital and its patients.
• Health care providers can temporarily enroll in Medicare to provide care.
  • CMS released Frequently Asked Questions on Medicare Provider Enrollment Relief including toll-free hotlines available for expedited enrollment.

To Facilitate the Use of Telehealth:

• Medicare will pay for visits furnished via telehealth across the country and including in patient’s homes.
  • Providers able to provide telehealth can bill for telehealth visits, such as therapy services, with new and established patients at the same rate as in-person visits.
  • The HHS Office of Inspector General is providing flexibility for healthcare providers to reduce or waive cost-sharing for telehealth visits paid by federal healthcare programs.
• Individuals can use interactive apps with audio and video capabilities to visit with their clinician for a range of services
• Providers can evaluate beneficiaries who have audio phones only.
• Clinical staff can be supervised by a physician using virtual technologies when appropriate.
• Billing for Telehealth Services during the Public Health Emergency:
  • For non-traditional telehealth services on or after March 1, 2020: bill with the Place of Service (POS) equal to what it would have been in the absence of a public health emergency, along with a modifier 95, indicating that the service rendered was actually performed via telehealth.
  • For traditional Medicare telehealth services: bill with the designated POS code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.

To Reduce the Burden of Paperwork:

• Paperwork requirements are temporarily eliminated to allow clinicians to spend more time with patients.
• Medicare will now cover respiratory-related devices and equipment for any medical reason as determined by clinician.
• Hospitals are not required to have written policies on processes and visitation of patients who are in COVID-19 isolation.
• Hospitals have more time to provide patients a copy of their medical record.

CMS previously announced Medicare quality reporting program exceptions and extensions for providers:

• For programs with deadlines in April and May 2020, data submission is optional and based on the facility’s decision.
• No data from services provided January 1 – June 30, 2020 will be used in CMS calculations for Medicare quality reporting and value-based purchasing programs.

Additional Information

CMS Emergency Declaration Health Care Providers Fact Sheet
Covers the blanket waivers issued by CMS as a part of its proactive steps to respond to the COVID-19 pandemic.

SAMHSA Federal Guidance
Guidance for substance use and mental health professionals regarding the practice implications of various federal policies being put in place during the public health emergency.

Expansion of Telehealth Benefits for Medicaid Beneficiaries
Medicare will temporarily pay clinicians to provide telehealth services for beneficiaries residing across the entire country.

Social Security Administration Authority in Public Health Emergency
Social Security Administration’s authority to ensure availability of sufficient health care items and services and that providers acting in good faith may be reimbursed and exempted from sanctions for noncompliance.

Nursing Community Coalition Letter Supporting Safety Measures for Healthcare Providers
NCC letter to congressional leadership in support of additional funding to support nurses and healthcare providers during COVID-19.

Mental Health Liaison Group Letter to Congress on Telehealth State Coverage
MHLG letter to congressional leadership in support of a temporary lift on telebehavioral health restrictions during the pandemic.

Mental Health Liaison Group Letter to National Association of Insurance Commissioners on Telehealth State Coverage
MHLG letter to insurance providers in support of a temporary lift on telebehavioral health restrictions regardless of insurance plan during the pandemic.

DEA and SAMHSA Buprenorphine and Telemedicine COVID-19 Guidance
Information about further flexibility from the DEA on prescription guidelines for telemedicine and buprenorphine prescription during this public health crisis.