What is the Public Health Emergency Expiration (What is the PHE)?

May 11^th marks the end of the Public Health Emergency (PHE) COVID-19, triggering the end of policy and regulation changes in reaction to COVID-19. During the COVID-19 PHE, the Centers for Medicare & Medicaid Services (CMS) implemented several regulatory changes that impacted the home health and hospice industry. These changes included the allowance of telehealth technology in patient care plans, changes in how agencies handle billing, and the expansion of several policies. However, with the PHE expiration, CMS is now determining which changes will remain. Learn what your post-acute agency needs to know as we enter a time post-COVID-19.

What you need to know right now

In case you’ve missed it, here’s a quick recap of news related to this topic:

Just last week, CMS posted additional end-of-the-PHE guidance for home health and hospice providers.

Additionally, the home health FTF was changed to end on December 31, 2024, rather than 150 days after the end of the PHE.

Permanent changes from PHE: What Home health and hospice agencies can expect with PHE expiration

Home health and hospice care agencies provide essential services that allow patients to receive medical care in the comfort of their own homes. During the Public Health Emergency (PHE), the COVID-19 pandemic changed the home health and hospice industry in unprecedented ways, including the introduction of new regulatory changes. While many of these changes were implemented out of necessity, some have proven so beneficial that they are now a permanent fixture of industry regulations. Here are some of those changes for post-acute agencies to note:

• Home Health Agencies (HHAs) can now leverage telecommunications technology to provide care, as long as it is included in the Plan of Care (POC) and does not replace crucial in-person visits. This is an excellent opportunity for agencies who are yet to adopt telehealth or Remote Patient Monitoring (RPM) to explore how to best integrate these technologies into their patient care plans. For those already using telehealth and RPM technology, these agencies can use this time to ensure their POC services are optimized for the best possible patient outcomes.
• Nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNS) can now order home health services, sign the plan of care, and certify Medicare eligibility for patients. To avoid any restrictions on these new providers certifying patients or ordering home health services, agencies should confirm their state's State Practice Act.
• Occupational therapists (OTs) can now conduct an initial and comprehensive assessment for all patients who require therapy services as part of their care plan. Home health agencies should assess their staff to ensure that OTs are fully integrated into the assessment process. Additionally, OTs should receive comprehensive training on how to conduct an initial assessment and accurately complete an OASIS. The end goal is to provide high-quality care that is both timely and efficient, by leveraging the skills and expertise of OTs. *It is important to remember that if a nurse is ordered at intake, the nurse must do the initial comprehensive assessment.
• Hospice programs can use pseudo-patients for competency testing, enabling new aides to start serving patients sooner without compromising patient health and safety.
• Providers that continue to experience the impacts of the PHE and require additional time to file their cost report may submit a request to their MAC for a 60-day extension.

Extensions after the PHE expires: PHE Expiration Impact on HHAs, Medicare Beneficiaries, and hospice providers

As the expiration date for the Public Health Emergency (PHE) approaches, there is growing concern about how its end will impact HHAs, Medicare beneficiaries, and hospice providers. To address these concerns the Medicare Payment Advisory Commission (MedPAC) recently released a report analyzing the payment patterns of various healthcare services during the pandemic. This report provides valuable insights into how beneficiary behavior and provider responses to the PHE have changed, and what the future of healthcare policy may hold. MedPAC's analysis of the PHE's impact on Medicare beneficiaries and healthcare providers offers a glimpse of what we can expect moving forward. These are the PHE extensions for home health agencies and hospice providers: 

• HHAs can continue to use two-way audio-video telecommunication technology as long as their documentation indicates the usage of audio-visual or both audio and visual components in their interactions with the patient. Simply put, agencies can access the technologies from a physician or allow practitioners for the face-to-face for 150 days after the end of the PHE. After this time, two-way audio/visual will not be allowed as a method to conduct face-to-face.
• Hospice providers can now conduct face-to-face encounters for patient recertification via telehealth, which offers greater flexibility and convenience for both patients and providers. However, it's important to note that there are two regulations that could affect this practice. First, during the PHE, CMS allowed practitioners to render telehealth services from their homes without reporting their home address on their Medicare enrollment while continuing to bill from their currently enrolled location. The waiver will continue through the end of December after the PHE ends. Secondly, CMS regulations will allow a total deferral to state law when the PHE ends, meaning that there will be no CMS-based requirement that a provider must be licensed in its state of enrollment. Hospice agencies that use out-of-state providers should keep aware of state laws that may prohibit this practice.

PHE Waivers to End with the Expiration of the COVID-19 Public Health Emergency

During the COVID-19 pandemic, regulatory waivers allowed healthcare providers to ensure their patients continued to receive the critical care they needed. However, as CMS implements lasting change in the home health and hospice sectors, there is a range of regulatory waivers the industry will bid farewell to.

For post acute agencies, the following regulations that were waived during the PHE will end at the conclusion of the PHE:

• Home Health Agencies (HHAs) are required to develop and implement an effective discharge planning process as per 42 CFR §484.58(a). During the PHE, HHAs were waived from assisting patients and their caregivers in selecting a post-acute care provider by sharing relevant and applicable data on quality measures and resource use measures for patients transferred to another HHA or discharged to a SNF, IRF, or LTCH. Agencies need to determine data sources, re-evaluate their discharge planning processes, and document patients' intent and the agency's assistance provided to them.
• HHAs are required to provide patients with a copy of their medical record, when requested by the patient, at no cost during the next visit or within four business days, as per 42 CFR §484.110(e). During the PHE, CMS allowed HHAs ten business days to provide a patient's clinical record instead of four. HHAs need to evaluate who is notified and the steps they take in gathering all the elements of the record, educate staff and develop a process to handle these requests timely.
• The requirement at 42 CFR §484.80(d) that HHAs ensure each home health aide receives 12 hours of in-service training in a 12-month period was postponed until the end of the first full quarter after the declaration of the PHE concludes. This will end at the conclusion of the PHE and will return to pre-PHE requirements at the end of the calendar year that the PHE ends. HHAs need to determine how many hours of in-service training each aide has received, develop a plan to complete 12 hours of in-service training by the end of the year and prepare for this change in 2024 by developing a schedule to provide aides 1 hour of training every month.
• During the PHE, the five-day completion requirement for the comprehensive assessment was extended to 30 days, and the 30-day OASIS submission requirement was waived, allowing agencies to submit the OASIS before submitting their final claim. HHAs need to instruct all staff on the importance of completing their documentation timely, ensure all staff are completing their initial evaluations and documentation within the first 5 days of care to allow for the most accurate OASIS assessment and work with their EMR to capture all OASIS assessments completed since the prior submission, which will be able to be submitted timely. to capture all OASIS assessments completed since the prior submission, which will be able to be submitted timely.
• In addition, the hospice regulations at 42 CFR 418.204 were amended to allow hospice providers to provide services in skilled nursing facilities during the PHE, but this waiver was not mentioned to be ending at the conclusion of the PHE.

Inpatient Hospice Units and the PHE Expiration: The Impact on Care

During COVID-19, the strain on healthcare providers was tested like nothing in recent memory. CMS responded to this need with a series of modifications and waivers aimed at easing the burden on providers and ensuring that patients continue to receive the care they need. Among the specialties that have seen significant changes are inpatient hospice units, home health, and hospice agencies, which have been granted a variety of flexibilities during the Public Health Emergency (PHE). In this article, we will explore the modifications and waivers that CMS has implemented for these services and their impact on providers, patients, and caregivers. The requirements CMS is modifying are as follows:

Inpatient Hospice Units:

• CMS has waived prescriptive requirements for the placement of alcohol-based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. But bulk containers will still need to be stored in a protected hazardous materials area.
• CMS has waived the requirement for quarterly fire drills that move and mass staff together and permitted a documented orientation training program related to the current fire plan, which considers current facility conditions.
• CMS has been waiving requirements that would otherwise not permit temporary walls and barriers between patients.
• CMS has established toll-free hotlines for physicians, non-physician practitioners, and Part A certified providers and suppliers who have established isolation facilities to enroll and receive temporary Medicare billing privileges.
• CMS has provided flexibility for provider enrollment, including expedited enrollment and opt-out enrollment.

Home Health & Hospice:

• CMS has modified the requirements for the QAPI program to narrow the scope of the program to concentrate on infection control issues while retaining the requirement that remaining activities should continue to focus on adverse events.
• CMS has waived the requirement for a nurse to conduct an onsite visit every two weeks to evaluate if aides are providing care consistent with the care plan.
• CY 2022 Home Health Prospective Payment System Final Rule (CMS 1747-F) finalized the provision for aide supervision for patients receiving skilled care every 14 days to now allow for one virtual visit, in rare circumstances, per 60-day episode per patient.

The COVID-19 pandemic changed the landscape of healthcare in an unprecedented way.  CMS has issued several modifications, waivers, extensions, and permanent changes to address the challenges healthcare professionals faced during this time. While some of these changes are set to expire in May, many have been made permanent to improve the quality of care for patients and increase access to necessary medical services.

How SimiTree Can Help

It is important for home health and hospice agencies to stay informed about these changes and work closely with CMS to ensure compliance while continuing to provide the best possible care to their patients.

By staying up-to-date and adapting to new requirements and regulations, agencies can continue to provide essential services to those in need. In addition to financial, clinical, and operational consulting, SimiTree offers clients a robust suite of services, including outsourced billing, coding, and revenue cycle management; executive recruiting, interim staffing, and other talent solutions; guidance through mergers and acquisitions; sales consulting and education; assistance with regulatory risk; and data analytics.

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