CMS releases FAQ on waivers and flexibilities ahead of PHE conclusion

Wednesday, May 10, 2023

The COVID-19 PHE is expected to conclude at the end of the day on May 11. To assist providers during this transition, CMS released an FAQ to clarify the expiration timelines for various Medicare waivers and flexibilities.

CMS will continue to pay providers approximately $40 per dose for administering vaccines through the end of the calendar year (CY) in which the vaccine’s emergency use authorization (EUA) declaration ends. The EUA declaration is distinct from, and not dependent on, the PHE, and it is still in effect. Starting January 1 of the year after the one in which the EUA declaration ends, CMS will align the administration payment rate for COVID-19 vaccines with the administration payment rate for other Part B preventive vaccines, which is currently $30 per dose.

These rates do not apply for Federally Qualified Health Centers, rural health clinics, or other settings that are paid at a reasonable cost for preventive vaccines and their administration. Medicare will also continue to pay approximately $36 plus regular administration fees for COVID-19 vaccines administered at home through the end of CY 2023.

The enforcement discretion that allows mass immunizers to bill Part B directly for vaccines furnished to skilled nursing facility (SNF) patients will end on June 20, 2023. “Beginning on July 1, 2023, SNFs will be responsible for billing vaccines furnished to SNF patients in a Part A stay,” stated the FAQ.

Medicare coverage of COVID-19 treatments will remain the same once the PHE ends. For diagnostic testing, beneficiaries can continue to receive COVID-19 PCR and antigen tests with no cost-sharing after the PHE ends if the test is performed by a laboratory and ordered by a physician.

The three-day stay requirement for SNFs will no longer be in effect once the PHE ends. Any covered SNF stay that begins on or prior to May 11, 2023, without a qualifying health stay (QHS) can continue for as many benefit days as the patient has available, given all criteria are met. However, covered SNF stays that begin after May 11 will require a QHS.

Many Medicare telehealth flexibilities have been extended through December 31, 2024. However, CMS noted that individuals will no longer be able to receive routine home care via telehealth under the hospice benefit once the PHE concludes.

The FAQ detailed billing practices for the following Healthcare Common Procedure Coding System (HCPCS) codes after the PHE conclusion:

  • Q3014 (originating site facility fee) should not be billed unless the beneficiary is located within a hospital and receives a telehealth service from an eligible distant site practitioner
  • G0463 (clinic visit) can be billed if a beneficiary is within a hospital and received an outpatient clinic visit, including mental/behavioral health, from a practitioner in the same physical location
  • C7900–C7902 (remote mental health services) can be billed if the patient is in their home and received a mental/behavioral health service from hospital staff through the use of telecommunications technology and no separate professional service can be billed

Additionally, hospitals will no longer be able to bill Q3014 “to account for resources associated with administrative support for a professional Medicare telehealth service,” according to the FAQ.

The Hospital Without Walls Initiative is set to expire along with the PHE. After May 11, hospitals can only bill for remote mental health services when no separate professional service is billable. Hospitals will also no longer be able to bill for outpatient physical/occupational therapy services provided to patients in their homes through telecommunication technology by hospital therapists and speech pathologists.

For nursing home residents and staff, COVID-19 vaccination reporting requirements will continue until CMS takes other regulatory action. Non-vaccine COVID-19 reporting requirements will remain in effect through December 2024.

The FAQ also details the timelines for Medicare Advantage, Medicaid, and Children's Health Insurance Program waivers and flexibilities. Along with the FAQ, revenue integrity professionals should review previous CMS guidance on the PHE conclusion—including its provider-specific fact sheets and transition roadmap—to ensure their organization is prepared.

NAHRI provides the following additional resources on the end of COVID-19 waivers and flexibilities:

On the April 25 NAHRI members-only Quarterly Call, NAHRI Advisory Board members Ronald L. Hirsch, MD, FACP, CHCQM, CHRI, vice president of R1 RCM, and John D. Settlemyer, MBA, MHA, CPC, CHRI, assistant vice president, revenue cycle, with Atrium Health, discussed the challenges facing provider organizations as they begin to unwind COVID-19 PHE waivers and flexibilities and tips for staying compliant. Hirsch and Settlemyer shared insights on managing waivers with various expiration dates, telehealth services after the PHE, monitoring COVID-19 accounts for patients discharged after May 11, using NAHRI’s “Significant Medicare PHE extensions and adjustments” resources as tools for auditing and monitoring, and more.

Revenue integrity professionals should review CMS’ most recent guidance on the end of the PHE and related waivers and flexibilities. Ensure that staff in other departments are aware of changes that will affect their work, and be prepared to provide additional education when necessary. Use NAHRI’s resources as a framework for auditing and monitoring affected services after the end of the PHE.


Editor’s note: Find more NAHRI resources on COVID-19 here.