SPECIAL BULLETIN COVID-19 #178: Temporary Provisions for COVID Surge: Post-Acute PA Exceptions and Hospital at Home Program
Temporary Suspension of Prior Authorization for Post-Acute Placements
Temporary Suspension of Prior Authorizations for New NH Admissions Who are Being Directly Discharged from a Hospital
Due to the COVID-19 Public Health Emergency (PHE) and to expedite a hospital’s ability to discharge patients to lower levels of care when medically appropriate, the prior authorization requirement for medically necessary new admissions who are being directly discharged from a hospital setting into a nursing home (NH) is waived for Medicaid beneficiaries between Sept. 1 – 30, 2021. The PA waiver applies to members receiving services under both NC Medicaid Direct and the Standard Plans. Standard Plans are permitted to require notification within three calendar days of skilled nursing facility admissions to facilitate care management and transitions to other care settings as clinically appropriate.
If the individual is expected to remain in the nursing facility past Sept. 30, 2021, the admitting nursing facility is responsible for verifying long-term care Medicaid eligibility with the local DSS and following the prior approval requirements noted in NH Clinical Policy 2B-1. The date on the FL2 form for Medicaid Direct beneficiaries should be the NH admission date. All claims are subject to audit.
Home Health Skilled Nursing Visits Reminder: Prior Authorization is not required prior to discharge from the hospital.
Due to the COVID-19 PHE and to expedite a hospital’s ability to discharge patients to a lower level of care when medically appropriate, Medicaid beneficiaries who would require medically necessary Home Health Skilled Nursing visits post-hospitalization do not require prior authorization. This applies to members receiving services under both Medicaid Direct and the Standard Plans. Standard Plans are permitted to require notification within three calendar days of Home Health admission to facilitate care management and care transitions. Home Health providers can begin services with verbal orders from the physician or as per CMS Interim Final Rule 42 CFR 440.70, licensed practitioners, as defined by CMS. See SPECIAL BULLETIN COVID-19 #72: Additional Home Health Clinical Coverage Policy Provisions for more information.
Temporary Suspension of Prior Authorization for Inpatient Rehabilitation Hospital and Long-Term Care Hospital Admissions under Managed Care
Due to the COVID-19 PHE, and to expedite a hospital’s ability to discharge patients to lower levels of care when medically appropriate, prior authorization for medically necessary Inpatient Rehabilitation and Long-Term Care Hospital admissions are waived from Sept. 1 – 30, 2021. Standard Plans are permitted to require notification of Inpatient Rehabilitation and Long-Term Care Hospital admissions within three calendar days of admission to those facilities, in order to facilitate care management and appropriate transitions of care to alternative care settings as clinically appropriate.
The prior authorization waiver also applies to transfers from acute inpatient hospitals to same levels of care, if necessary, to manage COVID-19 surge levels. Standard Plans are permitted to require notification of acute-to-acute facility transfers within three calendar days of transfer/admission. All claims are subject to audit.
Note: Under NC Medicaid Direct currently, a prior approval is not required
for an acute inpatient hospital or long-term care hospital admission.
Reminder of Swing Bed Reimbursement Rates
NC Medicaid would like to remind providers of the time-limited, targeted, enhanced swing bed reimbursement rates to provide additional financial support to hospitals that provide post-acute care services to COVID-19 positive (COVID+) Medicaid beneficiaries and non-COVID+ Medicaid beneficiaries transferred from other acute care hospitals as part of a surge response. Due to the COVID-19 public health emergency, this enhanced rate is still available to providers. For more information on provider eligibility, enhanced rates, activating enhanced rates and associated requirements, please refer to SPECIAL BULLETIN COVID-19 #115: Targeted Rate Increase and Associated Requirements for Swing Bed Services.
Temporary Availability of the Hospital at Home Program
Effective Sept. 1, 2021, the Acute Hospital Care at Home (HAH) program will be available to North Carolina hospitals that have been granted a waiver from CMS and service NC Medicaid beneficiaries. NC Medicaid is planning to implement this program to be effective Sept. 1 through Dec. 31, 2021, unless this flexibility is terminated prior to Dec. 31, 2021. The Acute HAH program is an expansion of the CMS Hospital Without Walls initiative as a part of a comprehensive effort to increase hospital capacity, maximize resources and combat COVID-19 to keep Americans safe. This program creates additional flexibility that allows for certain health care services to be provided outside of a traditional hospital setting and within a patient’s home. CMS guidance for participation in this program can be found on the CMS Acute Hospital Care at Home webpage.
There are several requirements that a hospital must meet to participate in the HAH program. These include:
- Having appropriate screening protocols in place before care at home begins to assess both medical and non-medical factors.
- Having a physician or advanced practice provider evaluate each patient daily, either in person or remotely.
- Having a registered nurse evaluate each patient once daily, either in person or remotely.
- Having two in-person visits daily by either registered nurses or mobile integrated health paramedics, based on the patient’s nursing plan and hospital policies.
- Having the capability of immediate, on-demand remote audio connection with an Acute HAH team member who can immediately connect either an RN or MD to the patient.
- Having the ability to respond to a decompensating patient within 30 minutes.
- Tracking several patient safety metrics with weekly or monthly reporting, depending on the hospital’s prior experience level.
- Establishing a local safety committee to review patient safety data.
- Using an accepted patient leveling process to ensure that only patients requiring an acute level of care are treated.
- Providing or contracting for other services required during an inpatient hospitalization. It is important to note that patients will only be admitted to the program from emergency departments and inpatient hospital beds, and an in-person physician evaluation is required prior to starting services at home.
Eligible hospitals will be reimbursed under the existing NC Medicaid inpatient hospital reimbursement methodology but will need to document the Condition Code of DR to identify patients who are “admitted to home.” All claims are subject to audit. The department will study and consider the experience of the HAH model of care during the pandemic to inform future policy direction. Standard Plans are permitted to require notification and review all HAH admissions for medical necessity.
NCTracks Contact Center: 800-688-6696