CHAD Connection - COVID-19 Edition March 26

Thank you for reading this special edition of the CHAD Connection. CHAD plans to release weekly editions of CHAD Connection over the next few months in order to adequately cover COVID-19-related news and updates. We are also encourage you to visit our COVID-19 webpage with up-to-date resources and links. We are excited to debut a new look for the COVID-19 webpage today with an updated format that is easier to navigate.

In this digest, you will find updates from the Bureau of Primary Health Care (BPHC), the National Association of Community Health Centers (NACHC), and the Departments of Health in both North Dakota and South Dakota. You will also find information we thought would be useful, including telehealth guidance, legislative updates, direction for human resources and employment law, and behavioral health resources for your patients.

As of March 19, health centers are being asked by the Bureau of Primary Health Care (BPHC) to complete an electronic survey twice a week. Health centers will report on COVID-19 testing, supply needs, telehealth, current operations, and workforce. This survey allows BPHC to assess the needs of the health center, share critical information, and understand additional needs related to training, funding, and other resources. Health center results will be sent to their state primary care association (PCA). When that information is shared with CHAD, we will share it back with the health centers and policymakers who could benefit from additional data on the impact of COVID-19 on health centers.

BPHC is also asking PCAs to complete a survey in a similar format once a week. PCAs will provide information regarding statewide issues and concerns, involvement with state emergency response efforts, and additional COVID-19 related details. BPHC will use the results to increase information sharing in the COVID-19 response efforts.

Medicaid Telehealth Provisions

Both North Dakota and South Dakota Medicaid offices have issued guidance that they will be reimbursing telehealth visits from a patient’s home. In North Dakota, they are covering audio-only visits. Please visit the FAQ pages for North Dakota Department of Human Services (NDDHS) for information specific to ND’s changes and the South Dakota Department of Social Services (SDDSS) for information specific to SD’s changes.
 

Medicare Telehealth Provisions

The federal legislation under consideration this week is expected to clear the barrier for health centers serving as distant sites for the purposes of telehealth throughout the COVID-19 emergency, though probably not at the prospective payment system (PPS) rate. We would then expect guidance specific to health centers and rural health clinics, but in the meantime, the Centers for Medicare and Medicaid Services (CMS) has issued guidance regarding telehealth reimbursement changes for Medicare.

The highlights include:

Starting March 6 and for the duration of the COVID-19 Public Health Emergency, Medicare will make payment for professional services furnished via video-audio technology to beneficiaries in all areas of the country in all settings (including from their home).
Providers can reduce or waive cost-sharing for telehealth visits.
CMS will not conduct audits to ensure that such a prior relationship existed between the provider and patient for claims submitted during this public health emergency

Blue Cross Blue Shield of North Dakota Provides Telehealth Update

On March 20, Blue Cross Blue Shield of North Dakota (BCBSND) provided a telehealth expansion update to the provider community stating that they have adopted the Centers for Medicare & Medicaid Services (CMS) guidance. The CMS guidance is in alignment with what will be considered allowable for BCBSND members temporarily during the declared COVID-19 emergency period. The changes are effective as of March 16. The following services are allowed during the COVID-19 emergency period:

Telehealth visits for new or established patients;

Virtual check-ins for established patients; and,
Digital telehealth (E-visits) for established patients.

Click here for the BCBSND telehealth guidelines. BCBSND encourages providers and suppliers to follow CDC guidelines when coding encounters related to COVID-19. Click here for the CDC ICD-10 CM official coding guidelines. 

Wellmark Blue Cross and Blue Shield Offers Virtual Health Care Update 

On March 17, Wellmark Blue Cross and Blue Shield announced that all Wellmark members would have access to virtual health visits with no cost-share. Wellmark is encouraging its members to take advantage of virtual visits with their primary care physician. The cost-share for such visits, including those for mental health reasons, will be waived effective March 16, and reassessed after 90 days (June 16, 2020). This update applies to all fully insured and self-funded plans.  

Wellmark’s Iowa and South Dakota network providers will receive the same fee for virtual visits as an in-person visit. These changes apply to all appropriate medical and behavioral health virtual visits with any Wellmark in-network provider.  

Click here for more information.   

As long as Health and Human Services Secretary Azar’s designation of a public health emergency remains in effect, Drug Enforcement Administration-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of their professional practice;
The telemedicine communication is conducted using an audio-visual, real-time, two-way interactive communication system; and
The practitioner is acting in accordance with applicable federal and state law.

Click here for additional details. 

On March 20, NACHC hosted a call for Congressional staff to hear from health center leaders and PCA colleagues. Multiple speakers shared stories about their current challenges, identified immediate and long-term needs regarding COVID-19, and specified ways Congress could help. Many of these examples will sound familiar to our health centers. Please listen to the recording and share with others who are interested in hearing about the crucial impact health centers are making caring for the underserved during this epidemic.

The third coronavirus relief package is expected to pass through the House this week, after clearing the Senate on Wednesday night (March 25). The $2.2 trillion package should provide a great deal of economic assistance to the health care providers, including health centers. The bill includes the following provisions: 

$1.32B for funding for CHCs in the form of supplemental awards for COVID-19 response;
Extension of mandatory funding through November 30, 2020 at current levels for the Community Health Center Fund, the Teaching Health Center Program, National Health Service Corps (NHSC);
Medicare reimbursement of telehealth as a distant site for Federally Qualified Health Centers (FQHCs) through the duration of the COVID-19 response at a rate to be set by the Secretary of the Department of Health and Human Services, based on a composite of current rates and the fee schedule;
Public Health and Social Services Emergency Fund of $100B – Grant funding for health care institutions on the frontlines of the crisis. Health centers are eligible to apply for this funding;
State and local governments will receive $150B to help alleviate budgetary pressures, with $8B set aside for tribal governments

 
As is evident after the last couple of weeks of the pandemic response, things can and do change up until the last minute. The bill is expected to be immediately signed by the president after it passes in the House.  Please see this summary from NACHC for a more detailed description of the provisions included in the third bill.

The US Department of Labor’s Wage and Hour Division (WHD) announced its first round of published guidance on March 25. The purpose is to provide information to employees and employers about how each will be able to take advantage of the protections and relief offered by the Families First Coronavirus Response Act. The "paid sick leave" and "expanded family and medical leave" sections take effect on April 1.

The guidance provides:

These documents address critical questions, such as how an employer must count the number of their employees to determine coverage, how small businesses can obtain an exemption, how to count hours for part-time employees, and how to calculate the wages employees are entitled to under this law.

The U.S Department of Labor has published a poster notice on its website that employers can use to satisfy the posting obligation provision of the FFRCA. The guidance announced is just the first round of information and compliance assistance to come from WHD. There will be more to come with additional fact sheets and more Q&A.

North Dakota and South Dakota emergency operations centers maintain a consistent process for requesting PPE and supplies. 

North Dakota requests must be made through the ND Health Alert Network (HAN) Asset catalog system at http://hanassets.nd.gov/. For questions or assistance with the ND HAN Asset system, request a call-back at 701-328-2270, or email Lindsey Heupel at lkheupel@nd.gov.

South Dakota requests must be emailed to COVIDResourceRequests@state.sd.us, faxed to 605-773-5942, or called into 605-773-3048 to ensure prioritization and coordination of requests. Medical facilities should have received an order form through their emergency preparedness contacts. If needed, forms may be requested by calling the phone number listed above. Although there is not a list of what is available, all requests will be reviewed and sent to the emergency operations distribution centers for fulfillment. Should the requested items not be available, notifications will be made by telephone.

CHAD received notice that the Association of Clinicians for the Underserved (ACU) may have supplies available on a rolling basis for health centers in the Dakotas. CHAD has collected supply requests and they have been submitted. Before shipping, the ACU will call to confirm availability and verify quantities of each item requested. 

Direct Relief is accepting orders from health centers with an existing partnership. Health centers that submitted an order last week will receive an email indicating that their items have shipped. All fillable orders are scheduled to ship on or before Friday, March 27. Health centers that do not have a current partnership with Direct Relief can request an application by emailing usaprograms@directrelief.org. Please note that Direct Relief cannot guarantee additional shipments of PPE or COVID-19 related supplies after enrollment due to the overwhelming number of requests.

SDDOH maintains a variety of listservs that health centers may find useful in receiving current information on COVID-19 including current guidance and scheduled calls. These links and archived calls can be found at the state COVID-19 website, https://covid.sd.gov.

Health Alert Network: https://sdhan.sd.gov

Laboratory Listserv: https://listserv.sd.gov/scripts/wa.exe?SUBED1=SDLABLIST&A=1

Epi Listserv: https://listserv.sd.gov/scripts/wa.exe?SUBED1=SDEPI&A=1

Healthcare-associated Infections Listserv: https://listserv.sd.gov/scripts/wa.exe?SUBED1=SDHCASSOCINFECTIONS&A=1

Office of Licensure and Certification Listserv: https://listserv.sd.gov/scripts/wa.exe?A0=SDOLC

Section 1135 waivers enable states to meet health care needs during times of disaster and crisis. Section 1135 waivers require both a declaration of national emergency or disaster by the President under the National Emergencies Act or the Stafford Act along with a public health emergency determination by the HHS Secretary under Section 319 of the Public Health Service Act. Section 1135 of the Social Security Act gives the Health and Human Services Secretary the authority to temporarily waive or modify certain Medicare, Medicaid, Children’s Health Insurance Program (CHIP), and Health Insurance Portability and Accountability Act (HIPAA).  

To streamline the 1135 waiver process, the Centers for Medicare and Medicaid Services (CMS) also issue blanket waivers. Any requests outside of the blanket waiver are addressed separately. North Dakota and South Dakota Medicaid submitted 1135 waiver requests to the CMS, and both states received responses on March 24. You can find the North Dakota waiver response here and the South Dakota waiver response here. Now that the waiver response has been approved, the states can move the make the operational changes needed to facilitate the change, so we expect further communication as changes are implemented.

Health centers may receive questions about immigration status and the public charge. It is important to note that testing and treatment for COVID-19 will not affect immigration status, and individuals should plan to seek medical care for COVID-19 without concerns about harming their immigration status. There are no known circumstances under which seeking COVID-19 testing and treatment would negatively impact a patient’s immigration status. NACHC has prepared answers to several FAQs regarding COVID-19, immigration, and the public charge here.

Health Center Program COVID-19 Frequently Asked Questions on the Bureau of Primary Health Care (BPHC) webpage were updated with responses to many new questions as of Wednesday, March 25. Much of the latest information pertains to funding, resources and oversight, providing care during emergencies, and telehealth, and accreditation. Click here to view the comprehensive list of FAQs.

With the passing of the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, the first round of COVID-19 funding for health centers was released on Tuesday, March 24. It was made immediately available to cover costs relating to preparation and response to the COVID-19 pandemic. Important things to note regarding the funding:

Funds can cover pre-award costs incurred as far back as January 20, 2020, and the performance period will be for 12 months. 
Award amounts over the base amount of $50,464 were based on each health center’s 2018 UDS data on the total number of patients and the number of uninsured patients. 
Health centers will have 30 days to provide budget and activity information to the BPHC. 
Because there is a need to track overall government spending on coronavirus preparedness and response, the funding was issued through H8C grants separate from health centers H80 operational grants. COVID-19 related costs covered by the H8C grant is required to be reported separately and should fall into one of three buckets: prevention, preparation, and/or response. 
The next round of funding will prioritize operational sustainability for health centers.

Additional highlights from the BPHC updates include:

BPHC will not make adjustments to FY2021 service area competition (SAC) funding based on patient targets and will explore how best to align FY2022 SAC funding with health center performance.  
Participants of the 340B program with concerns about eligibility or compliance are asked to contact the 340B prime vendor via email at apexusanswers@340bpvp.com or via phone at 1-888-340-2787 (Monday-Friday, 9:00 a.m. to 6:00 p.m. ET). For more information, visit the HRSA Office of Pharmacy Affairs COVID-19 Resources webpage. 
Health centers that are unable to demonstrate compliance with one or more health center program requirements due to the public health emergency may have some leniency with BPHC, depending on the circumstances of the noncompliance. If a particular requirement is not met within a specific manner or timeframe as indicated in the compliance manual, BPHC will consider the impact of the COVID-19 preparedness and response on the health center’s ability to demonstrate compliance.

Health center operational site visits (OSVs) have now been postponed indefinitely (rather than through the original date of April 30 as was previously stated). BPHC will reschedule OSVs as soon as it is practical.  
Health centers are expected to work with UDS reviewers throughout the remaining dates in March to discuss 2019 UDS reports so the data can be finalized on the usual timeline. If a health center absolutely cannot respond to their assigned reviewer, they should contact the UDS Support Line at 866-837-4357 (866-UDS-HELP) or by emailing udshelp330@bphcdata.net. 
Individuals that present at a health center solely for COVID-19 screening and have not received any other service should not be counted as a patient for UDS reporting. 
Deemed health centers that are operating within their approved scope of practice and are compliant with all FTCA requirements will be eligible for liability protection when providing services via telehealth to non-health center patients.  
A relatively new Program Assistance Letter, PAL 2020-01: Telehealth and Health Center Scope of Project, is available to review for questions about using telehealth to provide services at locations that are not in-scope service sites. From a scope of project policy perspective, this is allowable if the service being provided is within the approved scope, the clinician is a health center provider, and the individual receiving the service is a health center patient. HRSA strongly advised that a health center seek consultation and develop and maintain written policies that are compliant with health center program requirements.

There is interim guidance from the Health and Human Services (HHS) Office for Civil Rights that indicates that HHS will not impose penalties for noncompliance with HIPAA regulations in connection with good faith provision of services via telehealth during the COVID-19 emergency. Health center providers have the flexibility to provide telehealth using non-public facing communication products to communicate with patients such as Apple Face Time, Facebook Messenger video chat, Google Hangouts video, or Skype. Public-facing tools such as Facebook Live, Twitch, and TikTok are not allowable. The full guidance, including frequently asked questions, is available here.

The Joint Commission (TJC) has suspended all health center surveys beginning March 16 until further notice. The Accreditation Association for Ambulatory Health Care (AAAHC) has postponed all non-emergent surveys scheduled between March 18 through the end of May. If you have a survey scheduled with the AAAHC during this time frame, a representative will contact you to confirm the postponement and reschedule.  

If your accreditation/recognition through TJC, AAAHC, or the National Committee for Quality Assurance (NCQA) is due to expire between March 1 and June 30, 2020, the Health Resources and Services Administration (HRSA) will contact the accrediting/recognizing body to request a 60-day extension. HRSA will be revisiting and providing additional support to health centers with expiration dates beyond June as the situation evolves. Health centers transitioning to the 2017 standards will be contacted by NCQA six months before their expiration date to provide guidance. 

The emotional and physical toll that COVID-19 has had on patients and health care providers has already been significant. Some of the requirements that are in place to stop the spread of the disease can have additional health care consequences. Entire communities and families are social distancing, with some family members being further isolated due to exposure or illness. At a time when patients really want reassurance about their health, they have limited contact with their primary care providers.  

CHAD has created a letter that health centers can provide to patients that offers suggestions for emotionally managing this challenging time. This resource could be used in-clinic or even through the mail if necessary. You can find a copy of the letter here.  

Health centers may be able to utilize data within the EMR to identify patients who are at a higher emotional risk and can benefit from such a resource. For example, the electronic medical record may be able to ascertain patients who have had elevated PHQ scores over the last two months. These contacts may provide opportunities for telehealth visits and check-ins.  

North Dakota Department of Human Services Medicaid Webinar

The North Dakota Department of Human Services will hold a second webinar to provide updated information and answer Medicaid-related questions pertaining to Medicaid services and COVID-19.

Department officials will provide an update on the state’s Medicaid 1135 waiver request approved by CMS. The waiver will allow North Dakota to temporarily change select Medicaid requirements to ensure sufficient health care services and resources are available to meet the needs of individuals enrolled in the program during the COVID-19 pandemic.

There will also be an update on the Appendix K to the existing 1915(c) Medicaid waivers that informs CMS of requested changes to waiver operations due to the current state of emergency.

North Dakota Medicaid providers, advocacy organizations, and other stakeholders are invited to participate. The meeting will be recorded and available for later viewing on the department’s website at www.nd.gov/dhs/info/covid-19/program-policy.html.

Friday, March 27
12:00 pm MT/ 1:00 pm CT
The meeting will be available through Skype video conference at https://bit.ly/2QJtrHW.