Long-Term Care Facilities: What to Expect When the COVID-19 PHE Ends

Key provisions that provided flexibility to long-term care providers and helped alleviate administrative burdens will expire May 11, 2023.

Long-term care facilities (LTCs), skilled nursing facilities (SNF), and nursing facilities (together, LTC providers) were at the epicenter of the COVID-19 pandemic. In the United States, LTC providers faced uncertainty and risked their health and well-being to deliver care to the most vulnerable population in a climate of regulatory uncertainty and scrutiny, and, for a time, dealt with the absence of protective gear.

During the COVID-19 public health emergency (PHE), Centers for Medicare and Medicaid Services (CMS) addressed challenges for the delivery of care with diligence and agility. CMS implemented an array of waivers and flexibilities to ensure LTC patients could access preventive, routine, chronic, and acute care needs. LTC providers were able to use these regulatory flexibilities to alleviate administrative burdens in providing care to their residents. While LTCs have adapted to many of these flexibilities being rolled back over the last two years, many more are set to expire on May 11, 2023, when the PHE officially ends.

In anticipation of the PHE expiration, CMS issued guidance for LTCs that clarifies which regulatory flexibilities will continue and which flexibilities will end; key expiring provisions are summarized below. LTC providers also need to check with their respective state regulating agencies for specific policies that may expire with the PHE, impacting care planning, access to medical records, face-to-face requirements, and even Medicaid coverage. LTC providers should be aware of interim rules, such as reporting requirements.

Flexibilities Expiring for LTCs

Certain LTC flexibilities will end in conjunction with the May 11 PHE expiration, resulting in the following practices and procedures.

Administrative

• Three-Day Prior Hospitalization: LTC residents will be required to have a three-day prior hospitalization for coverage of an SNF stay.
• SNF beds will not be available for patients who do not meet SNF requirements, and reduced information requirements for post-acute discharges will end.
• PASRR: States and nursing homes will be required to conduct pre-admission screenings and annual resident reviews for new residents.
• All nurse aide training emergency waivers for states and facilities end on May 11. Facilities will have four months to ensure that all nurse aides hired during the PHE waiver period complete state-approved training.

Provider Enrollment

• CMS will resume normal application processing for LTC providers that submit enrollment applications.
• LTC providers that have opted out of enrollment will not be able to cancel their optout statuses earlier than prescribed in 42 CFR § 405.445.
• Provider enrollment hotlines will be shut down.

Medicare Appeals

• Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) in the Fee for Service (FFS) program, Medicare Advantage (MA) and Part D plans, and Part C and Part D Independent Review Entities (IREs) will be required to meet existing regulatory required elements for appeals, rather than solely using available information. 42 CFR § 422.562; 42 CFR § 423.562.
• Similarly, MACs and QICs will only be given flexibilities in the appeals process if good-cause requirements are met, consistent with regulatory authority.

Safety

• LTCs will be required to comply with prescriptive requirements for alcohol-based hand-rub (ABHR) dispensers.

COVID-19 Testing Protocols

• LTCs will no longer be required to test residents and staff (including volunteers) for COVID-19 under 42 CFR § 483.80(h).

Flexibilities for LTCs Being Extended

The following LTC flexibilities will continue beyond the PHE expiration on May 11.

Provider State Licensure

• Physicians and other practitioners will be able to continue billing Medicare for services provided outside of their state enrollment. CMS is deferring to state law on this issue.

Medicare Appeals

• MACs, QICs in the FFS program, MA and Part D Plans, and Part C and Part D IREs will continue to have flexibility to allow extensions to file an appeal, consistent with existing authority and regulatory requirements.

LTC Requirements That Will Sunset

The following LTC requirements will be in place, but will sunset after expiration of the PHE on May 11.

Provider Enrollment

• Providers will be able to continue rendering telehealth services without reporting their home address through Medicare enrollment. This waiver will continue through December 31, 2023.

Data Reporting

• LTCs will still be required to notify residents and residents’ representatives and families of any new cases of COVID-19. This mandatory reporting requirement will continue until December 31, 2024.

COVID-19 Testing Protocols

• Civil monetary penalties for failing to comply with testing requirements under 42 CFR § 483.80(h) will still be applicable until May 11, 2024.

Implications

As regulatory flexibilities expire, LTCs should prepare for the additional administrative burdens associated with admitting new residents that were the norm pre-pandemic but relaxed during the PHE. Further, while the PHE may be expiring, LTCs should ensure that their COVID-19 infrastructure remains intact so that they can continue to report cases of COVID-19 to residents and their families.

While other COVID-19-related protocols, specifically testing, will no longer be required, LTCs should be sure to maintain records because enforcement and accompanying civil monetary penalties will still apply.