hank you to everyone joined our July Grassroots Call. We had an incredible number of advocates on the line! We want to share a few resources as follow up to help facilitate your advocacy efforts:

Urge your Members of Congress protect rural health!

Send this letter to your Members of Congress, and urge them to support NRHA's rural health priorities! (also available via Connect as an attachment)
Links to the emails of House and Senate Health Legislative Assistants:

For email language specific to the Rural Hospital Closure Relief Act of 2019, click here!
PDF of the slides utilized during the call (also available via Connect as an attachment)
A recording of the July Grassroots Call is linked here (also available via Connect as an attachment)
Use this link to sign-up for the NRHA Rural Roundup, if you have not already!
The August Grassroots Call will be hosted on Wednesday, August 26th at 2PM EDT! Register in advance for this meeting and you will receive a confirmation email containing information about joining the meeting.

Please reach out to Maggie, Josh, or myself if you have any questions or concerns. We are here to serve as your voice on Capitol Hill, and we want to ensure that each of our members has the opportunity to help us do that! We sincerely appreciate your time, and we thank you for your advocacy. As always, we hope to be your voice. Louder.

Yesterday afternoon, Senate Majority Leader Mitch McConnell released the draft text of the next COVID-19 relief bill, the Health, Economic Assistance, Liability Protection and Schools (HEALS) Act. As it stands, this draft will be detrimental for rural health care practices and patients across the country.

The bill included very modest improvements for rural health care practitioners:

Minimal relaxation of Medicare Accelerated and Advance Payment Program offset and payback period (Sec. 302);
Provides the HHS Secretary with the authority to extend Medicare telehealth waivers until Dec. 31st, 2021 (Sec. 303);
Codifies a 5-year extension of RHC and FQHC Medicare telehealth flexibilities once the Public Health Emergency (PHE) ends (Sec. 304)
Appropriates an additional $25 billion for the Provider Relief (no rural-specific carve out), $225 million for RHCs, and 7.6 billion for CHCs via the Public Health and Social Services Relief Fund (link)

This bill will serve as a starting point for negotiations in the Senate, and Senator McConnell is facing push back from both sides of the aisle. Here's our message: the draft bill woefully omits key provisions that rural health care practitioners across the country desperately need.

Without the inclusion of an increase in dollars allocated to the Provider Relief Fund (accompanied by a rural-specific carve-out), the Rural Hospital Closure Relief Act, MAAP loan flexibility and forgiveness for rural providers, and other key provisions advocated for by NRHA and its members, the rural health care safety net will fall apart. Rural providers, not just hospitals, will close their doors for good, and disparities in access to care that have been persistent in rural communities for decades will be exacerbated. To put it simply, rural health will continue to struggle.

NRHA's latest letter to congressional leadership contains clear, concise recommendations that will enable rural providers to weather this crisis and provide stability to the health care safety net. We urgently request that you take action to protect rural health. Let your senators know the needs of rural health care. Request that they fight for these crucial provisions to protect America's rural health care practitioners and their patients.

A new Kaiser Family Foundation analysis finds the [COVID-19] growth rate is now higher in rural areas, where the population tends to be older, younger people are more likely to have high-risk health conditions, and there are fewer intensive-care beds." Now is the time to urge your Members of Congress to protect rural health! NRHA's latest letter to congressional leadership can be found here.

Urge your Members of Congress protect rural health!

Send NRHA's latest letter to Congressional leadership to your Members of Congress. Urge them to support rural health!
Urge your Representatives in the House to sign Rep. Torres Smalls' Dear Colleague letter to ensure that rural hospitals and health clinics receive adequate funding
Emails of House and Senate HLAs

Please utilize the following attachments:

A recording of the April Grassroots Call;
A PDF of the slides utilized during the call (also available via Connect as a PowerPoint);
Use this link to sign-up for the NRHA Rural Roundup, if you have not already!
Additionally, we wanted to share this updated fact sheet from CMS: on April 26, 2020 CMS will not be accepting any new applications for the Advance Payment Program. CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through HHS's Provider Relief Fund. Significant additional funding will continue to be available to hospitals and other healthcare providers through other programs.

The May Grassroots Call will be hosted on Wednesday, May 27th at 2PM EST! We hope this information is helpful, but again, please reach out to Maggie, Max, or myself if you have any questions or concerns. We are here to serve as your voice on Capitol Hill, and we want to ensure that each of our NRHA Grassroots Advocates has the opportunity to help us do that!

CONTACT YOUR SENATORS OVER JULY RECESS -

Today, Senators are taking a recess from Capitol Hill and beginning their state work period, which will last until July 17th. When they return from this break, they will discuss a fourth COVID-19 relief bill that will be finalized before August. This is not conjecture.

This relief package is certainly overdue for millions of Americans, and we need the Senate aware of how vulnerable rural populations have become in recent weeks. Hundreds of rural hospitals and other health care providers are on the brink of closure during a time when they are needed most. Twelve rural hospitals have closed this year, hundreds of rural health care practitioners have been furloughed or laid off, and the crisis is only growing more severe in rural areas. The July recess allows us the perfect opportunity to advocate. Now is the time for action.

Over the July recess, NRHA encourages you to attend a town hall, call, email, and/or write to your senators to inform them of needs of rural health care providers. Our team has crafted a specific list of actions/policies that will enable Congress provide relief to rural health care providers and their patients, but we need your help.

Use your voice to let your senators know that the next COVID-19 relief bill must prioritize the needs of rural Americans. Tomorrow, as we celebrate Independence Day, remember that there's nothing more patriotic than telling your elected officials about the priorities that matter to you. You can find a sample email here.

Urge Your Members of Congress to Support the Rural Hospital Closure Relief Act of 2019

(S.3103, H.R. 5481)

Rural hospitals are closing during this public health emergency. The Rural Hospital Closure Relief Act (S.3103, H.R. 5481) would update Medicare’s “Critical Access Hospital” (CAH) designation so more rural hospitals can qualify for this financial lifeline and continue to serve their communities with quality, affordable health care services. Small hospitals are the backbone of rural communities, and often the largest employers, yet more than 120 rural hospitals have closed nationwide in the past decade, with many more hospitals operating with negative margins. The Rural Hospital Closure Relief Act is the immediate fix to help rural hospitals facing extreme strains from the COVID-19 pandemic. Urge your Members of Congress to support this important legislation TODAY!

The Rural Hospital Closure Relief Act of 2019 (S. 3103; H.R. 5481) is critical bipartisan and bicameral legislation that will allow a limited number of struggling rural PPS hospitals to convert to Critical Access Hospitals (CAH). This legislation, introduced by Representatives Adam Kinzinger (R-IL) and David Loebsack (D-IA) and Senators Dick Durbin (D-IL) and James Lankford (R-OK), is being strongly considered for the next supplemental package. This bill will enable rural hospitals across the nation keep essential health services in their communities. NRHA CEO Alan Morgan has applauded the legislation, which will, "Keep many hospital doors open and enable communities to keep essential health services in their rural communities."

Our team has begun sounding the alarm to both the Administration and Congress regarding recent notifications from CMS directing PPP funds to be offset on labor expenses of Critical Access Hospital (CAH) and Rural Health Clinic's (RHC) cost reports. We were extremely disturbed when one of our members received the following notice:

"To prevent the duplication of benefits from the federal government - i.e., once via the SBA's PPP loan forgiveness and a second time in reimbursement for Medicare's share of providers' reasonable costs, funded by the loan forgiveness – providers must offset the amount of the SBA's PPP loan forgiveness from the operating expenses they report on their Medicare cost report… This is our assessment of the current CARES Act provisions in conjunction with Medicare policy; in the event of contrary legislation, we will reassess our position."

We are not aware of any other recipients of the PPP who are penalized for proper use of the program and are unclear why CMS would require this of rural health providers during the pandemic. As many of you know, the result of this cost-offset could result in a reduction in reimbursement for CAHs and RHCs for Medicare and Medicaid in most states. This could amount to a loss of 70-80 percent of their PPP loan forgiveness amount.

Our team is working tirelessly to elevate this issue, and we expect a congressional letter to be sent to CMS in the near future, but we still need your advocacy. Reach out to your Members of Congress and share NRHA's letter to CMS regarding this issue. We cannot allow CMS to, accidentally or otherwise, override the intent of Congress and have SBAs PPP to fund the Medicare trust fund. We believe this program was created to help keep employees working and we need your help!

Emergency Funding

Things to know:

CARES Act includes $130 billion in emergency relief for hospitals and practices

$150M in rural HRSA grants
Temporary relief from sequestration cuts
15% increase in COVID-19 Medicare PPS rates
$1B for tribes and HIS
Access to $562M in small business emergency relief funds
HRSA has issuing direct payments to FQHCs; payments range from $70,000 to $300,000

USDA under its Business & Industry loan guarantee program for nonprofits under the USDA Community Facilities grant & loan program.

Hospitals should be able to also file a claim with FEMA to recoup 75% of any direct and indirect costs associated with the epidemic
USDA Communities Facilities Guaranteed Loan, the USDA published in the Federal Register notification of guarantee loan payment deferrals for a period no longer than 180 days.

At this time it appears SBA loans are only available to 501(c)3 hospitals not municipally owned hospitals

language has been proposed to address this limitation
Federal Reserve may have loan or loan guarantees available for state governments and municipalities
Congress is currently putting pressure on the Small Business Administration to allow publicly owned rural hospitals to have access to the loan and grant provisions of the CARES Act. Congressional pressure is now being put on the SBA to include the 33% of rural hospitals and 18% of rural health clinics that are publicly owned.

If you are publicly owned,apply as soon as possible. If Congress is successful, the money in this program will go fast. Make sure you get your application in now.

Cutbacks are putting hospitals, practices, and other organizations at risk of closure

Accelerated payments forms currently available from MACs are being adjusted to reflected CARES ACT parameters; payment seem to be processing quickly

Hospitals seem to be filing different requests for each PTAN
Medicare would determine the max amount an entity would get.
Timing of when the money is applied for is important. Repayment of the loan will begin 121 days from the time the money is received.
Availability of the program may end when the State of Emergency is lifted.
Assistance is still needed for rural EMS, paramedicine and CHWs to pay for PPE, direct services and telemedicine equipment.

Congress is currently putting pressure on the Small Business Administration to allow publicly owned rural hospitals to have access to the loan and grant provisions of the CARES Act. As you know, the language lacked clarity and because publicly owned entities were excluded from previous SBA loans (and language in the Act did not specifically include them), many interpreted that as an overall prohibition. However, we are learning that this is not the intent of Congress. Congressional pressure is now being put on the SBA to include the 33% of rural hospitals and 18% of rural health clinics that are publicly owned.

If you are publicly owned, please apply as soon as possible! Congress may not win this fight with the SBA, but there is a good chance that they will. The money in this program will go fast. Make sure you get your application in now:

USDA Rural Development Deputy Under Secretary Bette Brand today announced that USDA is expanding servicing options for guaranteed lenders due to the COVID-19 pandemic. Apparently, USDA is expanding upon the deferral flexibility it announced March 31, 2020. More details on the Community Facility Loan Guarantee Program.
Please report if your lender is working with your facility to defer loan payments during the Covid-19 Public Health Emergency per the details released today and March 31, 2020.
$30B of the total $100B appropriation will be paid today. HHS writes, "recognizing the importance of delivering the provider relief funds in a fast, fair, and transparent manner, this initial broad-based distribution of the relief funds will go to hospitals and providers across the United States that are enrolled in Medicare. Facilities and providers are allotted a portion of the $30 billion based on their share of 2019 Medicare fee-for-service (FFS) reimbursements. These are payments, not loans, to healthcare providers, and will not need to be repaid."

HHS went on to say, "HHS is partnering with UnitedHealth Group (UHG) to deliver the initial $30 billion distribution to providers as quickly as possible. Providers will be paid via Automated Clearing House account information on file with UHG, UnitedHealthcare, or Optum Bank, or used for reimbursements from the Centers for Medicare & Medicaid Services (CMS). Providers who normally receive a paper check for reimbursement from CMS will receive a paper check in the mail for this payment as well, within the next few weeks."

Effective upon publication in the Federal Register through September 30, 2020, the USDA Community Facilities Direct Loan Program will temporarily allow borrowers with direct loans to request payment deferrals to assist those that are experiencing temporary cash flow issues due to the pandemic. See: https://higherlogicdownload.s3-external-1.amazonaws.com/NRHARURAL/04.17.2020%20-%20Stakeholder%20Announcement%20COVID-19%20CF%20Direct%20Loan%20Deferral%20Payments%20MODIFIED%20FINAL.pdf?AWSAccessKeyId=AKIAVRDO7IEREB57R7MT&Expires=1587410622&Signature=7giW18t5Xc8oegqtBWVO%2Bg%2FzXVw%3D
HHS announced $10B of the CARES Act Provider Relief Fund will be allocated to rural providers. The allocation will be allocated based proportionately on operating costs of rural hospitals and rural health clinics. Payments will start as early as next week. More details are in the attached Fact Sheet

https://www.hhs.gov/provider-relief/index.html

Payments will be made to providers for treatment of the uninsured for COVID related services.

Providers must register to receive these payments -0 signup begins April 27. Payments will be made based on the Medicare payment rates. More details are available using the following link.

https://www.hrsa.gov/coviduninsuredclaim

HHS has extended the deadline for reporting the number of COVID cases in order to participate in the $10B High Impact portion of the Relief Fund. The deadline was extended from 4/23 until 3:00 PM Eastern Time, Saturday, April 25. The link below provides the update. https://www.hhs.gov/about/news/2020/04/23/hhs-announces-more-time-for-hospitals-to-apply-for-covid-19-high-impact-payments.html

The Senate has passed a $484 billion relief package to replenish the depleted Small Business Administration's (SBA's) Paycheck Protection Program (PPP) and fund hospitals and coronavirus testing.

Bill Text

HHS Relief Summary

The relief package includes $825 million in funding for rural health clinics and community health centers, as well as $4.25 billion provided to areas based on relative number of COVID-19 cases.

NRHA has received guidance from the United States Treasury and Small Business Administration (SBA) on the Paycheck Protection Program (PPP). The newly released guidance has clarified that governmental owned facilities are eligible for PPP loans, if they meet the conditions below.

Is a hospital owned by governmental entities eligible for a PPP loan?

A hospital that is otherwise eligible to receive a PPP loan as a business concern or nonprofit organization (described in section 501(c)(3) of the Internal Revenue Code of 1986 and exempt from taxation under section 501(a) of such Code) shall not be rendered ineligible for a PPP loan due to ownership by a state or local government if the hospital receives less than 50% of its funding from state or local government sources, exclusive of Medicaid. The Administrator, in consultation with the Secretary, determined that this exception to the general ineligibility of government-owned entities, 13 CFR 120.110(j), is appropriate to effectuate the purposes of the CARES Act.

Official interim final rule language here.

Approval has been granted to allow facilities who desire to defer payments on Community Facilities (CF) Direct Loan accounts to proceed with requests for a due diligence review by USDA. This applies to those with cash flow issues due to COVID-19.

Details are in the Rules and Regulations of the Federal Register. This brief summary will provide those of you who are eligible and hope to apply some basic guidance:
Policy is effective May 12, 2020. Requests can be made until September 30, 2020.
Period of deferral is 1 year from the date the original payment is due. Repayment status for
borrowers that are current on payments as of March, 1, 2020.
Borrower must be in compliance with their current loan agreement and Agency regulations.
When possible, the reserve account should be used for payments before the approval of a
deferral.
Realize that interest may accrue on the account and that the interest may not be waived by Rural Development (RD) at the end of the deferral period.
Hardship must be demonstrated. Examples include loss of income, reduction in hours, or illness that impacts the ability to pay.
Documentation will be needed. Examples include cash flow statements, current approved income and expenses, a statement of temporary closure officially approved or ordered by the borrower or government entity. These need to be addressed in the narrative.
The narrative must include how the pandemic has impacted operations of the facility and hindered cash flow. It needs to reflect the circumstances were beyond your control.
The borrower has provided a proposed operations plan to address the loan repayment at the end of the agreement. There may be an ability to re amortize the remaining payments within the original loan term after the deferral expires.
The borrower has completed a workout agreement which includes the specificity of the payment deferral agreement including any waivers such as not reflect the loan delinquent nor charge the borrower late fees. That RD will reflect these waivers.
The borrower is requested to go through their respective State Director. The Director can approve a payment deferral on loans where the aggregate balance on principal and interest is $10 million or less. Administrator approval will be required on higher loan amounts.

Public Hospital Eligibility

I have received direct correspondence from them today and they believe that this language resolves the issue. Additionally, I asked one of our members who was previously denied if this clarity helped, and he said "Yes, the SBA attorney emailed our banker already and invited us to apply..." No, that doesn't address the issue at hand, but it does indicate that they want to help. Additionally, we have others who are fighting for this both within SBA and on Capitol Hill - - so let's work on getting clarity. Bottom line: APPLY! Don't lose your place in line - - this money will go fast. If additional clarity is needed per these concerns, we can hopefully get it resolved asap.
We at Hall Render have thoroughly reviewed the question of whether county and district hospitals are eligible to apply for a PPP loan as a nonprofit entity, and have concluded that the vast majority of these hospitals are eligible under the SBA guidance. As the nation's largest health care focused law firm, we have looked at this question for hospitals across the country. In every instance, the county or district hospital's application has been approved. We completely agree with NRHA's recommendation that county and district hospitals should apply for these loans, and as soon as possible. Even though Congress has appropriated another 320 billion for the PPP loan program, it is expected that this money will be gone in a week. If a hospital has concerns about whether it qualifies, it should contact legal counsel.

HHS Deputy Secretary Hargan has just announced how the rural funds in the $10 billion Relief Fund fought for by NRHA will be allocated. In depth details will be coming soon. The below are the details as Alan and I heard them on the conference call. I know that there will be lots of questions -- and much more detail is coming.(I was writing quickly - - please know that we will have formal documentation from HHS soon, but wanted to provide you with this information asap.)

Funds will be distributed by mid next week
The formula for distributing the fund was done in collaboration with the Federal Office of Rural Health Policy.
All non-metro counties will be included utilizing rural census tracts. However, ALL CAHs will also be included due to their "safety net provider" status according to Hargan.
The following entities will be entitled to receive funds:

Acute care rural hospitals
All critical access hospitals
Rural Health Clinics (independent and non-independent)
Rural Community Health Centers

Each facility will receive a minimum base rate in addition to a percentage of past operating expenses.
Funds will be directly deposited; there is no need to apply.
Each RHC will receive a minimum of $100,000, with the median receiving $124,000 and the average receiving $162,000
Each CAH will receive a minimum of $1,000,000, with the median receiving $3.6 million, and the average receiving a little over $4 million
There is no requirement that a hospital or RHC has to be independent. Funds for a hospital-affiliated RHC will go to the hospital, and a hospital affiliated with a larger system is still eligible.

FAQ Posted by HHS about the upcoming payments to providers: https://www.hhs.gov/sites/default/files/20200425-general-distribution-portal-faqs.pdf
SBA PPP program has 2 "size alternatives" to the 500 employee qualification criteria: Net Revenue less then 41.5 million or Net Equity of 15 million and net income of 5 million during the past 2 years.

Typically, if a hospital has employees of more then 500, they will have net revenue exceeding 41.5 million. If you have a large workforce in a low net revenue business, for example a Nursing Home you might have > 500 employees, with Net Revenue still below 41.5. SBA requires counting of all employees under their "affiliation regulations" which includes part timers. Likewise they require aggregating all net revenues from all services against the 41.5 net revenue limitation

Accelerated Payment Program

On April 26, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to health care providers and suppliers through these programs and in light of the $175 billion recently appropriated for health care provider relief payments. Further details are included on the attached Fact Sheet.
HHS activated the link for providers that received a portion of the $30B Relief Fund to input their 2018 net patient revenue to receive a portion of the additional $20B. According to HHS, all providers must provide the information including the attestation. The link to the portal is: https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html

Question: Do nonprofit hospitals exempt from taxation under section 115 of the InternalRevenue Code qualify as "nonprofit organizations" under section 1102 of the CARES Act?

Answer: Section 1102 of the CARES Act defines the term "nonprofit organization" as "an organization that is described in section 501(c)(3) of the Internal Revenue Code of 1986 and that is exempt from taxation under section 501(a) of such Code." The Administrator, in consultation with the Secretary of the Treasury, understands that nonprofit hospitals exempt from taxation under section 115 of the Internal Revenue Code are unique in that many such hospitals may meet the description set forth in section 501(c)(3) of the Internal Revenue Code to qualify for tax exemption under section 501(a), but have not sought to be recognized by the IRS as such because they are otherwise fully tax-exempt under a different provision of the Internal Revenue Code. Accordingly, the Administrator will treat a nonprofit hospital exempt from taxation under section 115 of the Internal Revenue Code as meeting the definition of "nonprofit organization" under section 1102 of the CARES Act if the hospital reasonably determines, in a written record maintained by the hospital, that it is an organization described in section 501(c)(3) of the Internal Revenue Code and is therefore within a category of organization that is exempt from taxation under section 501(a).16 The hospital's certification of eligibility on the Borrower Application Form cannot be made without this determination. This approach helps accomplish the statutory purpose of ensuring that a broad range of borrowers, including entities that are helping to lead the medical response to the ongoing pandemic, can benefit from the loans provided under the PPP.
16 This determination need not account for the ancillary conditions set forth in section 501(r) of the Internal Revenue Code and elsewhere associated with securing the tax exemption under that section. Section 501(r) states that a hospital organization shall not be treated as described in section 501(c)(3) unless it meets certain community health and other requirements. However, section 1102 of the CARES Act defines the term "nonprofit organization" solely by reference to section 501(c)(3), and section 501(r) does not amend section 501(c)(3). Therefore, for purposes of the PPP, the requirements of section 501(r) do not apply to the determination of whether an organization is "described in section 501(c)(3)."
As of May 3, 2020 This guidance is solely for purposes of qualification as a "nonprofit organization" under section 1102 of the CARES Act and related purposes of the CARES Act, and does not have any consequences for federal tax law purposes. Nonprofit hospitals should also review all other applicable eligibility criteria, including the Interim Final Rules on Promissory Notes, Authorizations, Affiliation, and Eligibility (April 28, 2020) regarding an important limitation on ownership by state or local governments. 85 FR

Payments were made today (May 6) by HHS from the $10B rural relief fund that is part of the Public Health and Social Services Emergency Fund. The allocation was a slightly different than that originally communicated by Maggie last week. We thank our friends at the Federal Office of Rural Health Policy for assisting in the distribution. Also -- a copy of the Terms and Conditions for the Rural Distribution. Each recipient will need to complete the attestation through the HHS portal.
The National Rural Health Association and the U.S. Small Business Administration (SBA) have partnered to present a series of regional webinars to highlight Paycheck Protection Program (PPP) funding available to support America's rural healthcare providers, titled Rural Providers and the Paycheck Protection Program.

There are still funds in the PPP, and there is potential for more funds to be appropriated for this program in forthcoming relief packages. Don't miss this opportunity. We strongly urge rural providers to apply to the PPP and save the dates of these important webinars.
The webinar format includes presentations by NRHA and SBA with an opportunity for questions and answers for both current loan recipients as well as those who have not yet applied. Please log in or dial in to learn more information on the PPP and to hear from:
For all the webinars listed below, you will be able to use a livestreamed link and/or join the call by phone.
Join the live streamed conversation to learn about what resources are available to you and your healthcare community.  For the regional webinar applicable to your state, please reference the date and times listed above. We are working on scheduling the additional regions, so if you don’t see your region posted, please stay tuned. Also, feel free to join in any of the other regional webinars if the times are convenient for you.

Monday, May 11th, SBA Region 1, SBA Regional Administrator, Wendell Davis

Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont
Time: 9:00-10:00 EST
Email: Wendell.Davis@sba.gov
https://attendee.gotowebinar.com/register/6242319343773219599

Monday, May 11th, SBA Region 7, SBA Regional Administrator, Tom Salisbury

Iowa, Kansas, Missouri, and Nebraska
Time:  10:00-11:00 AM CT
https://attendee.gotowebinar.com/register/1444657530564555276

Monday, May 11th, SBA Region 9 , SBA Associate Administrator Field Operations, Michael Vallante

Arizona, California, Guam, Hawaii, and Nevada
Time: 2:00-3:00 PM PT
https://attendee.gotowebinar.com/register/6011043669927811084

Tuesday, May 12th , SBA Region 8 , SBA Director, Office of Rural Affairs, Dan Nordberg

Colorado, Montana, North Dakota, South Dakota, Montana, and Utah
Time:  9:00-10:00 AM MST
https://attendee.gotowebinar.com/register/6769512079535175436

Tuesday, May 12th , SBA Region 6 , SBA Regional Administrator, Justin Crossie

Arkansas, Louisiana, New Mexico, Oklahoma, and Texas
Time:  11:30-12:30 AM CT
https://attendee.gotowebinar.com/register/2939686580596122124

Tuesday, May 12th , SBA Region 5 , SBA Regional Administrator, Rob Scott

Ohio, Minnesota, Wisconsin, Illinois, Indiana, and Michigan
Time:  3:00-4:00 PM EST
https://attendee.gotowebinar.com/register/5388352851723074828

HHS Extends Deadline for Attestation, Acceptance of Terms and Conditions for Provider Relief Fund Payments to 45 Days

The Department of Health and Human Services has extended the deadline for healthcare providers to attest to receipt of payments from the Provider Relief Fund and accept the Terms and Conditions. Providers will now have 45 days, increased from 30 days, from the date they receive a payment to attest and accept the Terms and Conditions or return the funds. As an example, the initial 30-day deadline for providers who received payment on April 10, 2020, is extended to May 24 from May 9, 2020. With the extension, not returning the payment within 45 days of receipt of payment will be viewed as acceptance of the Terms and Conditions.

We have had several questions about the calculation of the rural hospital distribution. HHS published the actual formula Friday. Attached is an example for a hospital with total expenses over $10M. The formula link is:

https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/payment-allocation-methodology/index.html

Additional PPP Seminars:

Tuesday, May 19th

SBA Regions 2 & 3, SBA Regional Administrator, Steve Bulger

SBA Region 10, SBA Regional Administrator, Jeremy Field

Washington, Alaska, Oregon, Idaho

Additionally, the recordings of the first six webinars are listed below:

NRHA's Technical Assistance Center produced the position paper COVID-Related Funding Accounting and Cost Reporting Issues.

NRHA positions are not authoritative but will hopefully provide some guidance and our current position. As you know there are many unanswered questions and information changes often. Our general position is that providers should seek the advice and counsel of their financial auditors and reimbursement consultants. We will continue to post new developments through NRHA Connect and other social media venues. NRHA staff is continuing to actively work with the various agencies to get clarity on the issues.
SBA issued the application for PPP Loan forgiveness with instructions. The form is attached or can be found on the following link: https://www.sba.gov/document/sba-form--paycheck-protection-program-loan-forgiveness-application

HHS issued a press release on May 20 reminding providers that the attestations for distributions from the Provider Relief Fund General Distributions ($20B and $30B) are due by June 3.

The press release is attached and available by the link below:
https://www.hhs.gov/about/news/2020/05/20/providers-must-act-june-3-2020-receive-additional-relief-fund-general-distribution-payment.html

HHS released new FAQs (6/2) related to the Provider Relief Fund distributions. The FAQs are attached and available at the link below. One on page 5 expands on the definition of allowable expenses and determination of lost revenue. There are new FAQs scattered throughout the FAQ document: https://www.hhs.gov/sites/default/files/provider-relief-fund-general-distribution-faqs.pdf

On June 4, the H.R.7010, the Paycheck Protection Program Flexibility Act of 2020 was passed in the Senate by unanimous consent. This bill amends the PPP and provides small business recipients with necessary flexibility to receive the forgivable loans they need to keep their businesses open and their employees on their payrolls. Specifically, H.R.7010:

Increases the loan forgiveness period from eight weeks to 24 weeks;
Changes the 75/25 payroll / non-payroll requirement for loan forgiveness to 60/40
Increases the loan repayment period from two to five years;
Allows payroll tax deferral for PPP recipients; and
Extends the June 30 rehiring deadline to December 31, 2020.
The full text of this legislation is available at: https://www.congress.gov/bill/116th-congress/house-bill/7010/text. The bill had previously passed the U.S. House of Representatives and was sent to President Trump for his signature. Following its enactment, the SBA will be required to update its loan forgiveness application and process.

Today's big news is the announcement of three new distributions from the Provider Relief Fund: (1) $10 billion to safety net hospitals, (2) $10 billion in second round to hotspot hospitals; and (3) $15 billion to providers that serve Medicaid patients and were not touched in earlier distributions, including dentists, OB-GYNs, assisted living facilities and other home and community-based service providers, behavioral health and substance abuse providers, and pediatricians.

These distributions are very important as these Medicaid providers serve the most vulnerable populations, including those with low incomes and many minority patients. Details follow with the press release, but I also recommend you take a look at Deputy Secretary Eric Hargan's remarks for further context and information.

Medicaid Providers to Receive $15 Billion in Funding From the Provider Relief: HHS, through HRSA, announced additional distributions from the Provider Relief Fund to eligible Medicaid and Children's Health Insurance Program (CHIP) providers that participate in state Medicaid and CHIP programs and have not received a payment from the Provider Relief Fund General Allocation. We anticipate this will be around 275,000 providers. On Wednesday, HHS will open an enhanced Provider Relief Fund Payment Portal that will allow eligible Medicaid and CHIP providers to report their annual patient revenue, which will be used as a factor in determining their Provider Relief Fund payment. The payment to each provider will be at least 2 percent of reported gross revenue from patient care; the final amount each provider receives will be determined after the data is submitted, including information about the number of Medicaid patients providers serve.

Safety Net Hospitals to Receive $10 Billion in Funding from Provider Relief Fund: HHS is also announcing the distribution of $10 billion in Provider Relief Funds to safety net hospitals that serve our most vulnerable citizens. This will go to about 768 hospitals. For this distribution, safety net hospitals are defined as those with a Medicare Disproportionate Payment Percentage of 20.2 percent or greater, average Uncompensated Care per bed of $25,000 or more, and profitability of 3 percent or less as reported to CMS.
Hotspot Hospitals to Receive $10 Billion in Funding AFTER Submitting Additional Information: HHS also announced a second round of funding to hospitals in COVID-19 hotspots to ensure they are equitably supported in the battle against this pandemic. To determine their eligibility for funding under this $10 billion distribution, hospitals must submit their information by June 15, 2020 at 9:00 PM ET. To collect that data, on Monday, June 8, 2020, HHS sent communications to all hospitals asking them to update information on their COVID-19 positive-inpatient admissions for the period January 1, 2020, through June 10, 2020. This information will be used to determine a second round of funding to hospitals in COVID-19 hotspots.

HHS posted additional FAQs yesterday (June 8). One set deals with additional/updated data on the number of COVID cases for the period 1/1 - 6/10/20 - see pages 27-28 attached. HHS is preparing for a second distribution for High Impact Area funding and is seeking updated data. The data must be input into the portal no later than 9:00 PM Eastern Time Monday 6/15. Additional FAQS are scattered throughout the document. The entire FAQ file is attached and can be directly accessed by the link: https://www.hhs.gov/sites/default/files/provider-relief-fund-general-distribution-faqs.pdf
The SBA has issued an updated forgiveness application and instructions including an "easy" one for selected organizations. The applications and instructions are below: https://www.sba.gov/funding-programs/loans/coronavirus-relief-options/paycheck-protection-program
Yesterday, the Senate passed legislation (S. 4116) by unanimous consent that would extend the application deadline for the Small Business Administration's Paycheck Protection Program (PPP) until August 8th. There are approximately $130 billion in unspent money, and this extension would delay the PPP application deadline until the Senate goes on its August recess. We are awaiting action from the House of Representatives on this bill, and we expect that they will act quickly.

Additionally, our team is working to advance legislation that would allow affiliated rural hospitals, or rural hospitals that also have a nursing home or rural health clinic (and thereby may not meet the 500 person threshold), to qualify for the PPP. This legislation has been introduced in the House of Representatives by Reps. Terri Sewell and Michael Guest, and we expect it to be introduced in the Senate soon. If you know of anecdotal stories of rural hospitals/facilities that would benefit from this increased flexibility, please contact our team!

On July 6, CMS updated MLN Matters Article SE20016 to clarify how Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) can apply the Cost Sharing (CS) modifier to preventive services furnished via telehealth. This update includes: Additional claim examples, New section on the RHC Productivity Standard
“U.S. Secretary of Agriculture Sonny Perdue today announced that the United States Department of Agriculture (USDA) is taking steps to increase private investment in rural communities across the country by making it easier for lenders to access four flagship loan programs.”
On July 10 HHS announced funding of over $1 billion to 500 hospitals including certain rural and small metro hospitals with payments ranging from $100,000 to $4,500,000 for rural designated providers and $100,000 to $2,000,000 for the other providers from the Provider Relief Fund.

HHS issued updated FAQs for the Relief Fund which included the formula for the rural distribution. The excerpted pages are attached along with the full set of FAQs as of today. The FAQs and other information are available on the link below.
https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/faqs/index.html

HHS finally posted some timeframes for Provider Relief Fund reporting, attached and at: https://www.hhs.gov/sites/default/files/provider-post-payment-notice-of-reporting-requirements.pdf?language=en

More detailed instructions will be posted by August 17th. Providers that have expended all funds by 12/31/20 can file one report by 2/15/21. Those who have unexpended funds at 12/31/20 must submit a second and final report no later than 7/31/21.

HHS issued an update on the reporting of CARES Act/Provider Relief Fund distributions. The following is an excerpt from the guidance attached and available at the following link.

The purpose of this notice is to inform Provider Relief Fund (PRF) recipients that received one or more payments exceeding $10,000 in the aggregate from the PRF of the timing of future reporting requirements. Detailed instructions regarding these reports will be released by August 17, 2020.
These reporting instructions will provide directions on reporting obligations applicable to any provider that received a payment from the following CARES Act/PRF distributions:

General Distributions:
Initial Medicare Distribution
Additional Medicare Distribution
Medicaid, Dental & CHIP Distribution
Targeted Distributions:
High Impact Area Distribution
Rural Distribution
Skilled Nursing Facilities Distribution
Indian Health Service Distribution
Safety Net Hospital Distribution

Notice on Timing of Reports

The reporting system will become available to recipients for reporting on October 1, 2020.
All recipients must report within 45 days of the end of calendar year 2020 on their expenditures through the period ending December 31, 2020.
Recipients who have expended funds in full prior to December 31, 2020 may submit a single final report at any time during the window that begins October 1, 2020, but no later than February 15, 2021.
Recipients with funds unexpended after December 31, 2020, must submit a second and final report no later than July 31, 2021.
Detailed PRF reporting instructions and a data collection template with the necessary data elements will be available through the HRSA website by August 17, 2020.
https://www.hhs.gov/sites/default/files/provider-post-payment-notice-of-reporting-requirements.pdf

Remaining Questions

Can you clarify if a CAH that does not have an existing swing bed program can utilize this waiver to begin taking in swing bed patients?
AWV in the RHC still requires a face-to-face with the provider. This is something that will need to be clarified as far as if an audio-visual synchronous visit would qualify. The AWV in other settings is not subject to a provider in-person service.
If a PPS has a large volume of Covid-19 can they move the healthier swing bed patients to the local CAH?
We have the same question in the EMS space. Is there any avenue to access FEMA funds to support EMS response?
Will Respiratory Therapists be covered? Many pulmonary rehab clinics have suspended operations and I wonder if the proposed legislation will cover their ability to work with respiratory patients?
Will they pay via the current methodology mentioned in the legislation as of yesterday called a "composite method"? This is similar to how they pay us for CCM the average of what they pay FFS folks. Granted that is a short and non-complete definition and we don't know what stages the negotiations are in now.
Will they create new codes and/or rules such as how long this will last considering it is authorized as an emergency measure?

Will we report on a 1450 or the 1500 form and what revenue codes will be used?
Use POS 02 for telehealth? Use the old -GT modifier?

Question: Will there be any relief around bad debt – will that go up 2%?
Is there any more information on the one-time grants that were originally part of the proposal. The accelerated payment option is great for hospitals immediate cash crunch, but in the end, if we have to pay it all back, how does that help with lost revenues and extra staff expenses ?
What are the best options? There is an option for an SBA loan with loan forgiveness under certain circumstances having to do with the retention of employees. However, if we opt for that, we are not eligible for other provisions under the Act. Recognizing that every organization is different, whatever guidance you're able to give would be greatly appreciated.
The new Paycheck Protection Program may be very beneficial to our small CAH. However, does anyone know if participating in this would limit or adversely affect what monies have been set aside for hospitals?

There is a need to harmonize these programs at the federal level:

SBA Loans/PPP
CMS Accelerated Payment Program
HHS $100B hospital grant program

For example, if a CAH receives accelerated payments from Medicare, and gets loan forgiveness for payroll expenses under the PPP, that CMS not consider the PPP money a rebate on payroll expenses, thus lowering Medicare reimbursement on the cost report. This could cause an unexpected over-payment that would be difficult for the CAH to manage on settlement.

Are Critical Access Hospitals eligible for FEMA Public Assistance? On FEMA's grant portal, hospitals were not listed as an "organization" type on the application; only governmental entities were included.
Did we ever get clarification on the impact of this on loan forgiveness for CAH and the Medicare cost report treatment? Will this be considered like a grant and not offset? We spoke about this recently and you indicated that this was an open question.
If a rural provider (hospital, RHC) received money from either or both Tranche 1 and Tranche 2, do they have to account for the use of the money or lost revenue separately for each allocation and not commingle the uses? It seems like if a provider received funds from Tranche 1, Tranche 2 and the Rural fund that it might be hard to document the COVID related expenses or lost revenue if the provider were not hit hard by COVID.

Capacity

UPDATE:

Things to know:

1. The Office of the Inspector General released a report on hospital bed capacity. Key Things to know from the report:

Hospitals reported that their most significant challenges centered on testing and caring for patients with known or suspected COVID-19 and keeping staff safe. Hospitals also reported substantial challenges maintaining or expanding their facilities’ capacity to treat patients with COVID-19. Hospitals described specific challenges, mitigation strategies, and needs for assistance related to personal protective equipment (PPE), testing, staffing, supplies and durable equipment; maintaining or expanding facility capacity; and financial concerns.

Testing

UPDATE:

Things to know:

1. The FDA list of all current authorized tests, updated daily:

https://www.fda.gov/medical-devices/emergency-situations-medical-devices/emergency-use-authorizations#covid19ivd
FDA webpage that addresses available diagnostic and therapeutic medical devices in response to COVID-19:

Here is a list of Laboratories and Manufacturers that are Offering Tests for COVID-19:

https://www.fda.gov/medical-devices/emergency-situations-medical-devices/faqs-diagnostic-testing-sars-cov-2#offeringtests

Additional diagnostic questions should be submitted to: COVID19DX@fda.hhs.gov
As a reminder, any concerns regarding fraudulent products, including tests, should be sent to: FDA-COVID-19-Fraudulent-Products@fda.hhs.gov

Remaining Questions

Has anyone had any luck getting FEMA to cover proactive COVID testing in extremely high risk pops like MSAWs or homeless, etc? Or getting public health to support it?
We are beginning to explore what we need to do to "re-open" some services. With that has come the discussion of screening our patients for COVID prior to services. I haven't read anything in regarding to insurance coverage for screening COVID 19 testing. Will there still be no patient responsibility for COVID 19 testing that is done for a screening purpose prior to a surgery for example?

Medicaid Changes

UPDATE:

Things to know:

Georgetown University Health Policy Institute Analysis:\

Families First Coronavirus Response Act (P.L. 116-127) and the CARES Act (P.L. 116-136). Families First temporarily increased the federal Medicaid matching rate (FMAP) by 6.2 percentage points for all states and territories starting January 1, 2020 through the end of the public health emergency.
In addition, the CARES Act established a $150 billion Coronavirus Relief Fund for state, local, tribal and territorial governments, of which about $110 billion is estimated to go to states in 2020. The CARES Act provides some other funding to states as well.
Recommended the Administration to not enact the Medicaid Fiscal Accountability rule (MFAR)

Virtual & Televisits

UPDATE:

Things to know:

RHCs can bill for Virtual Communication Services, $14. Should be short visits.
Pending: Allowance for RHCs and FQHCs to conduct reimbursable telehealth visits

RHCs and FQHCs designation as a "distant site" for purposes of billing for Medicare Telehealth Visit and E-visits is contained in Phase 3 of COVID 19 Emergency Funding bill – pending approval

Allows RHC and FQHC to be paid their encounter rate or a combined rate between FFS and the encounter rate, not just the $14.
Multiple states have already made changes or in the process of allowing the RHC/FQHC encounter rate to be paid for telehealth visits for Medicaid patients (i.e., Washington, South Carolina)
Time required to update/change billing systems to allow for new codes

Can RHC clinicians to deliver full range Telemedicine services from home if they are on quarantine?

No, that was not proposed due to site restrictions on RHCs. What you can do is bill it to Part B with a Place of Service Code 02 and add the provider's home address into their Medicare Part B enrollment (either individual or group).
You would be paid what the Medicare Fee Schedule pays (ie around $70 or so for a 99213).
You would keep up with the cost of this service and disallow it on the cost report as private practice time or possibly include in Cost Center 79 of the Independent RHC Cost Report (either way the cost would not be included in the calculation of the AIR).

Can the distant site practitioner furnish Medicare telehealth services from their home? Or do they have to be in a medical facility?

There are no payment restrictions on distant site practitioners furnishing Medicare telehealth services from their home.
The practitioner is required to update their Medicare enrollment with the home location.
The practitioner can add their home address to their Medicare enrollment file by reaching out to the Medicare Administrative Contractor in their jurisdiction through the provider enrollment hotline.
It would be effective immediately so practitioners could continue providing care without a disruption.
More details about this enrollment requirement can be found at 42 CFR 424.516.
If the physician or non-physician practitioner reassigns their benefits to a clinic/group practice, the clinic/group practice is required to update their Medicare enrollment with the individuals' home location.
The clinic/group practice can add the individual's home address to their Medicare enrollment file by reaching out to the Medicare Administrative Contractor in their jurisdiction through the provider enrollment hotline
Source: https://www.cms.gov/files/document/provider-enrollment-relief-faqs-covid-19.pdf

NARHC will be providing a webinar on May 3rd at 2pm to review telehealth billing for RHCs
Telehealth kits are available from the following vendors:

CMS has released RHC/FQHC Telehealth Guidance: New and Expanded Flexibilities for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) During the COVID-1. (NOTE: the CMS document ALSO goes into cost reporting issues, accelerated payments, consent for care management/ virtual communication services, home health agency shortages, etc.)

Telehealth highlights include:

New HCPCS code for RHC/FQHC telehealth services G2025

RHC/FQHC to be paid $92 per approved telehealth service - "approved" list found here:

https://www.cms.gov/files/zip/covid-19-telehealth-services-phe.zip

Expect the AIR/PPS rate until July when they finalize MAC payment system updates

Know the proper use of modifier -95

Expansion of Virtual Communication Services to include digital eVisit codes 99421-99423 for coding - but G0071 for CMS billing. Medicaid/commercial insurance may want either or both.

NOTE: Costs associated with the delivery of a telehealth visits will be reported on the RHC cost report line 79, non-reimbursable RHC costs. RHC telehealth costs and telehealth visits will not be counted when determining the RHCs cost-per visit. There is the potential for telehealth to be highly detrimental to an RHC.
CMS released State Medicaid & CHIP Telehealth Toolkit: Policy Considerations for States Expanding Use of Telehealth, COVID-19 Version
The Centers for Medicare & Medicaid Services (CMS) today issued a second round of sweeping regulatory waivers and rule changes to provide greater flexibility to the healthcare system in the wake of the Covid-19 Public Health Emergency (PHE). These changes largely centered on these items:

Flexibilities needed to ramp up diagnostic testing
Expand beneficiaries' access to telehealth services
Some standout flexibilities that have been expanded include:

Practitioners now allowed to provide telehealth services, including physical therapists, occupational therapists, and speech language pathologists
Hospitals may bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is located at home
Hospitals may bill for services furnished remotely by hospital-based practitioners to Medicare patients registered as hospital outpatients, including when the patient is at home when the home is serving as a temporary provider-based department of the hospital

Good afternoon, everyone. Please find attached for the Ways and Means Republicans discussion draft and one-pager outlining their priorities for telehealth extensions going into the next COVID-19 relief package debate. It is expected that Senate Majority Leader Mitch McConnell will release a proposal this week.

Included in the attached discussion draft is the permanent removal of geographic and originating site restrictions allowing Medicare beneficiaries to utilize telehealth services from their homes as well as the permanent lifting of restrictions on Federally Qualified Health Centers and Rural Health Clinics to provide telehealth services to Medicare beneficiaries.
Bill: https://higherlogicdownload.s3-external-1.amazonaws.com/NRHARURAL/46a280ce-127f-4dfd-9715-1643cfb7a764_file.pdf?AWSAccessKeyId=AKIAVRDO7IEREB57R7MT&Expires=1595537025&Signature=FojjeeUhNpO2f%2BXDJ6daK7D0Qpk%3D
Handout: https://drive.google.com/file/d/1cudo9c9NMLgMtZy9Z50VR4Qmmxvj0gmH/view?usp=sharing

Remaining Questions

Are there provider type restrictions as to who could provide the telehealth services (FQHC, RHC)? Would the facility be reimbursed if a pharmacist practitioner furnished clinical or telehealth services?
Are mental health providers or services included/allowed for telehealth?
I had a question about virtual inpatient provider assessments and specifically regarding the use of iPads, iPhones, etc. for inpatient visits and assessments. I have been asked about the use of iPads to be used for additional patient/provider interactions other than the daily physician in- person assessment. I understand different healthcare systems are offering this as a means to save PPE and also protect staff from added contact. Apparently, the iPads system has also provided an additional resource for patients to have virtual visits with family members. Any thoughts or examples anyone has would be appreciated?

Treatment & Best Practices

UPDATE:

Things to know:

ASHP (American Society of Health-System Pharmacists) has completed an evaluation of the evidence related to proposed treatments for people with COVID-19
American Academy of Pediatrics has issued guidelines on well child visits, sick visits and immunizations.
University of Washington has posted their COVID-19 protocols and algorithms
CDC is hosting a second update call on Wednesday, April 8, 2020 at 4:00 to 5:00 pm ET.

Two topics shared with CDC to cover in terms of content:

Masks for the general public, to wear or not to wear
Testing for Covid 19 capacity in rural U.S. currently

To submit your questions in advance, please e-mail ruralhealth@cdc.gov with "Rural Health Update 4/8" in the subject line.
You must register to attend, please click here to register. NRHA is pleased that CDC is engaging with rural stakeholders on this important topic.

Hello NRHA members: we wanted to alert you to this new guidance from CDC in case it might be of interest. According to CDC, It is intended for state and local emergency medical planners and all healthcare facilities, especially facilities in rural areas. This guidance outlines considerations around the transfer of patients, staff, and supplies between healthcare facilities to optimize patient care, balance resources, and to minimize use of crisis care standards. One strategy is to identify relief healthcare facilities and either establish a federal, state, or regional Medical Operation Coordination Cell (MOCC) or coordinate with an existing MOCC. This guidance offers considerations for jurisdictions around patient safety and relief healthcare facility operations.

Staffing

UPDATE:

Things to know:

Hospitals can rapidly expand their healthcare workforce

Private practice clinicians and their trained staff may be available for temporary employment
Physician assistants and nurse practitioners, to the fullest extent possible, in accordance with a state’s emergency preparedness or pandemic plan can be utilized by hospitals. These clinicians can perform services such as order tests and medications that may have previously required a physician’s order where this is permitted under state law.
Waives the requirements that a Certified Registered Nurse Anesthetist (CRNA) is under the supervision of a physician.
Blanket waiver to allow hospitals to provide benefits and support to their medical staffs, such as multiple daily meals, laundry service for personal clothing, or child care services while the physicians and other staff are at the hospital and engaging in activities that benefit the hospital and its patients.

As clinics and other providers see declines in visits and demand, they may be a source of labor for hospitals and other high needs areas

Transition would take time, effort, paperwork
See here for more details: https://www.dailyyonder.com/healthcare-system-simultaneously-has-too-many-and-not-enough-healthcare-workers/2020/04/01/?utm_source=twitter&utm_medium=RuralAssembly&utm_campaign=healthcare-system-simultaneously-has-too-many-and-not-enough-healthcare-workers

The Centers for Medicare & Medicaid Services (CMS) temporarily suspended a number of Medicare rules regarding front-line medical staff for hospitals, clinics, and other healthcare facilities. The fact sheet detailing the information is at: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

Doctors can now directly care for patients at rural hospitals, across state lines if necessary, via phone, radio, or online communication, without having to be physically present. Remotely located physicians, coordinating with nurse practitioners at rural facilities, will provide staffs at such facilities additional flexibility to meet the needs of their patients.

Nurse practitioners, in addition to physicians, may now perform some medical exams on Medicare patients at skilled nursing facilities so that patient needs, whether COVID-19 related or not, continue to be met in the face of increased care demands.
Occupational therapists from home health agencies can now perform initial assessments on certain homebound patients, allowing home health services to start sooner and freeing home-health nurses to do more direct patient care.
Hospice nurses will be relieved of hospice aide in-service training tasks so they can spend more time with patients.

Remaining Questions

Pending Issue: Expedited process for credentialing new providers with payers is needed

Swing Bed Waiver 1135

UPDATE:

Things to know:

Allows CAHs and rural (non-CAH) swing-bed hospitals to move patients from their acute care beds to swing beds for extended care services without a 72-hour prior hospitalization
NRHA will continue working to get the waiver extended to cover urban PPS hospital transfers to rural swing beds.
CMS is formally waiving the 72-hour qualifying hospital stay requirement for patients transferred to a CAH Swing Bed from an acute care hospital. The waiver letter may be found here. This waiver is effective from March 1, 2020 until the declared end of the current Public Health Emergency (PHE).

Remaining Questions

Does it need to be COVID related, or not?

Impact of Quarantine

UPDATE:

Things to know:

Risk vs. benefits of quarantines/closures

Deleterious impact on patients from job losses, closures and disruption of normal business

Impact routine chronic illness and preventive care

Reduce access for vulnerable patients
Halt in diabetes self-management and other chronic disease management services

Remaining Questions

Are there provider type restrictions as to who could provide the telehealth services (FQHC, RHC)? Would the facility be reimbursed if a pharmacist practitioner furnished clinical or telehealth services?
Are mental health providers or services included/allowed for telehealth?

Service Delivery/Reopening

ACTION NEEDED: It is critical that every rural hospital (and practices) gather information on lost revenue, and increased expenses to prepare for the process of applying for relief.

UPDATE:

Things to know:

Providers are significantly increasing telephone visits and telehealth visits for patients with non-COVID-19 care

Proactively reaching out to patients to convert office visit to telephone visit or e-visit or to describe new parameters for protecting them during visit

Curbside treatment
Designated areas in practice for routine care

Hospitals without walls

Communities to take advantage of local ambulatory surgery centers with capacity to provide hospital services - they enroll and bill as hospitals during the emergency declaration as long as they are not inconsistent with their state’s Emergency Preparedness or Pandemic Plan. The new flexibilities will also leverage these types of sites to decant services typically provided by hospitals such as cancer procedures, trauma surgeries, and other essential surgeries.
CMS will now temporarily permit non-hospital buildings and spaces to be used for patient care and quarantine sites, provided that the location is approved by the state and ensures the safety and comfort of patients and staff.
CMS will also allow hospitals, laboratories, and other entities to perform tests for COVID-19 on people at home and in other community-based settings outside of the hospital.
In addition, CMS will allow hospital emergency departments to test and screen patients for COVID-19 at drive-through and off-campus test sites.
Physician-owned hospitals can temporarily increase the number of their licensed beds, operating rooms, and procedure rooms.
Hospitals can bill for services provided outside their four walls. Emergency departments of hospitals can use telehealth services to quickly assess patients to determine the most appropriate site of care, freeing emergency space for those that need it most.

Providers are starting to discuss plans for reopening elective procedures and routine care

Reopening procedures may include

extending hours to catch up from canceled procedures
Screening 2-3 days pre-op
allowing only 2-3 patients in waiting room
scheduling patients by like groups (i.e., Medicare in afternoon)
Pre-register and discharge by telephone or televisit
Resource: https://higherlogicdownload.s3-external-1.amazonaws.com/NRHARURAL/Road-Map-to-Recovering-2.pdf?AWSAccessKeyId=AKIAVRDO7IEREB57R7MT&Expires=1586892436&Signature=nTu1tYZpPFjq4gSOH6NYe8iy7ys%3D

Can a transfer between facilities of an already admitted patient occur in overload situations?

It appears that planning for the transfer of patients from urban centers to rural hospitals is already occurring.

If one hospital has a resource that another doesn't and the patient would best be cared for there, could a transfer occur? Also could transfers of already admitted patients occur between facilities with overload situations?

If a patient has medically necessary needs that your hospital can't provide, even in "normal" times, you'd expect to send the patient to another hospital for that care. While CAHs most often transfer to larger secondary/tertiary PPS hospitals in that situation, I am aware of times CAHs have transferred to another CAH with different clinical capabilities for a specific issue, or in the case of graduating to Swing Bed, to get the patient closer to home and family. Of course, in "normal" times, the impact of an acute transfer to a CAH and their 96 hour length average stay situation would need to be considered by the receiving CAH.

In these decidedly NOT "normal times", the recent CMS blanket waivers (summary updated Wednesday at https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf) , allow much wider latitude for CAHs to use their beds as is best for the overall healthcare system in their regions. The 25 bed limit and 96 hour length of stay limit have been waived as well as the 3-day acute stay Swing Bed requirement for "those people who experience dislocations, or are otherwise affected by COVID-19." So assuming the transferred patient would either still meet inpatient criteria OR have a qualifying daily Skilled Need (if being admitted to Swing Bed at the receiving facility) AND the patient/family are agreeable to the transfer, it would not seem to be an issue to transfer to another CAH if the receiving CAH is also supportive. While the waivers allow significant flexibility in location of care, staffing, licensure, and a range of billing items, it's important to note that what has not changed is that acute patients still need to have "acute" needs, and post-acute patients still need have "post-acute" needs when Medicare is billed as such.

It would be valuable to pre-plan or even "table-top" the process with your likely CAH partners to ensure optimal patient safety and communication if the process is put into action, and that your billing/coding teams are both on the same page.

The Centers for Medicare & Medicaid Services issues new recommendations to update earlier guidance provided by CMS on limiting non-essential surgeries and medical procedures. The new CMS guidelines recommend a gradual transition and encourage health care providers to coordinate with local and state public health officials, and to review the availability of personal protective equipment (PPE) and other supplies, workforce availability, facility readiness, and testing capacity when making the decision to re-start or increase in-person care.

The new recommendations can be found here: https://www.cms.gov/files/document/covid-flexibility-reopen-essential-non-covid-services.pdf

The Centers for Medicare & Medicaid Services (CMS) today issued a second round of sweeping regulatory waivers and rule changes to provide greater flexibility to the healthcare system in the wake of the Covid-19 Public Health Emergency (PHE). These changes largely centered on these items:

Flexibilities needed to ramp up diagnostic testing
Expand beneficiaries' access to telehealth services

CMS also released the attached additional guidance on Rural Health Clinic (RHC) and Federally Qualified Health Centers (FQHC) billing and providing additional flexibilities related to the following:

Additional claims submission and processing instructions
Information on cost-sharing related to COVID-19 testing
Additional information on telehealth flexibilities
Information on provider-based RHCs exemption to the RHC payment limit

Remaining Questions

Have any rural providers formalized plans with a larger system in the region to help off-load "healthy-sick" patients (non-C-19) to assist the urban hospitals make space for surge, and gain a little volume in your rural or CAH?
Can one CAH transfer a COVID-19 patient to another CAH, if the receiving CAH has needed resources to provide the best care for the patient?
As we approach warmer weather, and everyone wanting to get out and about we anticipate staff wanting to travel. Would like to know if any other hospitals have implemented policies related to employee travel? If so, could you please share?

Supplies

UPDATE:

Things to know:

PPE shortages continue for hospitals, clinics, practices, and EMS.

Working with local business to locate and procure PPE supplies
We have started a process through Medline to reprocess masks. Just beginning today so not a lot of details yet.
Tapping into Emergency Preparedness supplies

Resource for proper PPE use: https://www.etrainetc.com/covid19PPE-emicrosim
Many hospitals are enlisting community volunteers to make masks:

https://www.deaconess.com/How-to-make-a-Face-Mask/Documents-Mask/Mask-Information

Also trying tourniquets cut in strips for the earloops and that the fabric wrapped bungee cords have multiple small diameter long rubber bands inside the mesh. These could be cut open and used as earloop material as well.

https://anest.ufl.edu/clinical-divisions/alternative-n95-mask-production/

Filters being used for homemade masks

Suggestion of 3M Filtrete 1900 furnace filters (cut to size of her mask). They currently are $19.99 per filter on Amazon.com.

Remaining Questions

How to request ventilators from FEMA.

Communication

UPDATE:

Things to know:

NRHA has worked with Legato Communication to develop a toolkit to assist with communication regarding COVID-19 in rural communities. The resources can be customized to your local facility or community.

Remaining Questions

RHC Suspension of Services

UPDATE:

Things to know:

HHS Awards 100 Million to health centers:

Remaining Questions

Is there any guidance for RHC's to limit their hours of operation? We have been receiving questions asking if they can reduce their hours because of the reduction of patient services and cancellations.
Do you know if there is anything that would stop our funding/grant opportunities if we furloughed some of our workforce based on the third COVID stimulus package?
Are there penalties for suspending services at a satellite RHC due to decreased patient volume or need to protect staff from COVID-19?