SPECIAL BULLETIN COVID-19 #82: Expedited Hardship Advances and Retroactive Targeted Rate Increases for Skilled Nursing Facilities and Adult Care Homes Serving COVID-positive Patients

Wednesday, May 6, 2020

This bulletin replaces SPECIAL BULLETIN COVID-19 #68 in its entirety. 

NC Medicaid is directing increased financial assistance to North Carolina Skilled Nursing Facilities (SNF) and Adult Care Homes (ACH) to support addressing the increased costs of caring for COVID positive (COVID+) residents in a congregate care setting. This targeted assistance, which is retroactive to April 1, 2020, addresses:

  1. Increased cost of heightened safety and health practices required to limit the spread of COVID-19 in a congregate care facility in which at least two individuals have been confirmed as COVID+ (a “COVID Outbreak,” as defined below). 
  2. Facilitation of safe and timely discharge of COVID+ patients from acute health care settings to residential settings for convalescence and/or rehabilitation (“COVID-Response”).

This bulletin addresses two provider types that are currently experiencing extreme challenges in limiting the spread of COVID-19. However, NC Medicaid continues to consider potential rate adjustments for other provider types that address COVID-related care needs of Medicaid beneficiaries.

COVID Outbreak Definition: NC Medicaid defines a COVID Outbreak in a congregate living setting as two or more laboratory-confirmed cases, as documented by the Division of Public Health (DPH). Further, NC Medicaid defines an Outbreak as being ended (“Outbreak Ended”) when 28 calendar days have passed since the date of symptom onset of the last case. For purposes of rate eligibility, this Outbreak Ended definition also applies to COVID-Response sites. These parameters are subject to change as more information is obtained during outbreak investigations.

NC Medicaid’s Targeted Increased Financial Assistance to SNFs and ACHs

  • Either type of facility may request an Expedited Hardship Advance
  • An SNF COVID-Outbreak site will receive the following:
    • An increased Per Patient Reimbursement base rate for all Medicaid residents in the facility 
    • An additional per patient reimbursement rate for each Medicaid patient with a confirmed COVID+ diagnosis who meets the CMS defined U07.1 diagnosis criterion 
  • An SNF COVID-Response site accepting a COVID+ resident discharged from an acute health care setting will receive the same assistance as a SNF with an Outbreak.
  • An ACH COVID-Outbreak site will receive increased service hours and an increased unit rate for individual Personal Care Services (PCS) for every resident in the facility.

Detailed Technical Information

Expedited Hardship Advances

The Expedited Hardship Advance process enables an eligible provider to receive an interim payment of up to 125% of two months’ reimbursement based on the facility’s prior claims history. To be eligible, a SNF or ACH must be an enrolled provider, must request the advance and must either be confirmed by DPH as meeting the definition of “COVID Outbreak” or confirmed by NC Medicaid as volunteering to be a COVID-Response site.

To access an Expedited Hardship Advance:

  1. Prepare an official request on provider letterhead, signed by an authorized individual, that contains:
    • Statement that a Hardship Advance is requested and the dollar amount 
    • NPI of the provider who will receive the advance
    • Nature of the need; i.e., COVID-Outbreak site or COVID-Response site
    • Name, telephone number and email address of the provider’s contact person.
  2. Email the request to Medicaid.Hardships@dhhs.nc.gov
  3. NC Medicaid’s Hardship Advance team will confirm the provider’s COVID-Outbreak or COVID-Response status, then prepare a Hardship Interim Payment Advance Agreement.
  4. The advance may not exceed two times the average of Medicaid payments made to the provider in January and February 2020, times a factor of 1.25.
  5. The release date of the advance is scheduled when the provider accepts the terms and conditions in the Hardship Interim Payment Advance Agreement.
  6. Once the Hardship Advance payment is released to the provider, it becomes a receivable owed by the provider to NC Medicaid. No interest or penalty will be assessed on this special receivable.
  7. While the Hardship Advance is outstanding, claims processed to a status of PAID in the NCTracks checkwrites will not pay to the provider, but instead will be applied to reduce the receivable balance. This process reconciles actual services performed against the Interim Payment Advance.
  8. Once the receivable balance is satisfied by the value of processed PAID claims, normal payment to the provider through the checkwrite recommences.

SNF Rate Increases

  • Current facility Medicaid patient per diem base rates will increase by $86.64 for SNF COVID-Outbreak sites and SNF COVID-Response sites.
  • Both types of SNFs will receive an additional per diem amount of $561.00 for each COVID+ Medicaid resident during their treatment period.

SNF Billing Rates

  • SNF billing rate for Non-COVID+ residents in an SNF COVID-Outbreak site or SNF COVID-Response site = April 1, 2020 facility base rate + $86.64. (Claims submitted should not include U07.1 diagnosis code)
  • SNF billing rate for COVID+ residents in an SNF COVID-Outbreak site or SNF COVID-Response site = April 1, 2020 facility base rate + $86.64 + $561.00. (Claims submitted must include U07.1 diagnosis code)

Note: SNF providers will receive a rate letter confirming their facility-specific increased rates. The increased rates will be activated in NCTracks on April 28, 2020, and will be retroactively applicable to claims submitted with dates of service April 1, 2020 or later. 

Criteria for Reimbursement at the Additional COVID-19 Per Diem Rate(s)

  • To qualify for the targeted increased rates, a SNF must meet one of the following conditions:
    • SNF must have been identified as meeting the definition of a SNF COVID-Outbreak site, as defined by NC Medicaid in collaboration with the Division of Public Health (DPH).
    • SNF must have identified itself to NC Medicaid as a COVID-Response site. A COVID-Response site must not have or had an open Corrective Action Plan with any DHHS division for infection control-related deficiencies at any point on or after April 1, 2020.
  • SNF COVID-Outbreak site status and COVID+ resident status must be reported to the NC Medicaid Finance Section monthly. Please note: the reporting deadline is the 5th day (or following business day) of the month following the reporting period. For April, 2020 reports, the deadline will be extended to Monday, May 11, 2020. 
  • Status reports can be obtained on the Cost Reports and Assessments web page
  • Email report to Medicaid.ProviderReimbursement@dhhs.nc.gov.
  • The NC Medicaid COVID+ Status reporting template must be completed as required and received by NC Medicaid by the 5th day (or following business day) of the month following the reporting period to continue reimbursement at the increased rates. 
  • For patients who are COVID+, COVID-19 diagnosis code U07.1 must be present on the claim submitted for reimbursement.
  • The increased rates apply to Medicaid beneficiaries only.

SNFs may bill at the increased base rate for Non-COVID + patients retroactive to the first day of the month that the facility is determined to be a SNF COVID-Outbreak site. SNFs may only begin billing at the COVID+ patient rate for each COVID+ resident only from the date that the SNF is identified as a SNF COVID-Outbreak site. 

SNF COVID-Outbreak site status and COVID+ resident status will determine the time period that facilities remain eligible to bill at the increased rates. A SNF COVID-Outbreak site or SNF COVID-Response site is no longer eligible for the increased rates when 28 calendar days have passed since the date of symptom onset of the last COVID+ resident in the SNF (see definition of Outbreak Ended above).

ACH COVID-Outbreak Site PCS Reimbursement Increase

Both the rate increase and the additional hours for ACH COVID-outbreak facilities apply to all residents in the Outbreak facility, not just those with a COVID-positive diagnosis. Facilities should submit claims with the COVID-19 diagnosis code U07.1 for those individuals with a confirmed COVID+ diagnosis. Claims submitted for an individual who does not have a confirmed COVID+ diagnosis should only have the individual’s current diagnosis code listed on the claim.  

  1.  An ACH COVID-Outbreak site will be assigned NPI-specific rates that allow them to be reimbursed the increased rates for services provided. The current 15-minute unit rate will be increased to $7.50 per unit for all Medicaid PCS beneficiaries in an ACH COVID-Outbreak site. Providers should bill their usual and customary charges.
  2.  An ACH COVID-Outbreak site may bill up to 100 additional service hours per month for each beneficiary with current prior approval up to 80 hours per month. 
  3.  An ACH Outbreak site may bill up to 40 additional service hours per month for each beneficiary with current prior approval greater than 80 hours per month. 

Note: ACH PCS providers will receive a rate letter confirming their provider-specific increased rate. The increased rates are projected to be activated in NCTracks on May 4, 2020, and will be retroactively applicable to claims submitted with dates of service April 1, 2020 or later. 

Criteria for receiving the additional COVID-19 rate(s):

  • To qualify for the targeted increased rates, an ACH must have been identified as an ACH COVID-Outbreak site, as defined by NC Medicaid in collaboration with DPH.
  • ACH COVID-Outbreak site status and COVID+ resident status must be reported to the NC Medicaid Finance Section monthly. Please note: the reporting deadline is the 5th day (or following business day) of the month following the reporting period. For April, 2020 reports, the deadline will be extended to Monday, May 11, 2020.
  • Status reports can be obtained on the Cost Reports and Assessments web page
  • Email report to Medicaid.ProviderReimbursement@dhhs.nc.gov.
  • The NC Medicaid COVID+ Status reporting template must be completed as required and received by the 5th day (or following business day) of the month following the reporting period. to continue reimbursement at the increased rates.
  • COVID-19 diagnosis code U07.1 must be present on the claim submitted for any COVID+ resident. 

ACHs may bill at the increased base rate and service hours from the date that the ACH is identified as an COVID-Outbreak site. The increased rates and hours will be retroactive to the first day of the month in which the ACH is identified as an Outbreak site. ACH COVID-Outbreak site status along with COVID+ resident status will determine the time period that facilities remain eligible to bill at the increased rates. An Outbreak site is no longer eligible for the increased rates when 28 calendar days have passed since the date of symptom onset of the last COVID+ resident in the ACH (See definition of Outbreak Ended above).

IMPORTANT NOTE: NC Medicaid will systematically reprocess claims meeting the referenced criteria at a date yet to be determined. Providers do have the option to resubmit their claims. NC Medicaid will provide updates and additional details regarding the reprocessing schedule in upcoming Medicaid bulletins. 

Additional Resources

ICD-10 code U07.1 COVID-19 criteria can be found at https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf.

Contact

Medicaid Contact Center: 888-245-0179