How is FEMA adding Critical Supplies to the Supply Chain?  Right now, FEMA is expediting movement of critical supplies from the global market to medical distributors in various locations across the U.S.  Each flight contains critical personal protective equipment (PPE), to include gloves, gowns, goggles, and masks in varying quantities.

Four strategies to address Supply Chain needs are being pursued concurrently:

1. Preservation to limit unnecessary use of PPE and other supplies.
2. Acceleration of industrial manufacturing is required to help meet the urgent demand placed on the market.
3. Expansion of the industry is taking place.
4. Allocation of critical resources based on data-informed decisions.

On the Acceleration piece, I want to highlight the following updates:

• FEMA is expediting movement of critical supplies from the global market to medical distributors in various locations across the U.S.
• As an example of this effort, FEMA coordinated an air bridge for flights from Asia beginning Sunday, March 29 which delivered 80 tons of much needed PPE supplies to New York, New Jersey and Connecticut.

FEMA Delivering 80 Tons of PPE to NY, NJ and CT

• The second flight landed in Chicago this morning. Ohio is likely tomorrow.  FEMA has scheduled additional flights and is adding more daily.
• Each flight will contain critical PPE (gloves, gowns, goggles, and masks) in varying quantities. FEMA will not have detailed visibility on the amount of PPE until the flights are loaded overseas.
• Upon arrival, PPE will be provided, in varying quantities, first to medical distributors in areas of greatest need; then, the remainder will be infused into the broader U.S. supply chain. Prioritization will be given to hospitals, health care facilities, and nursing homes around the country.
• Additionally, in some cases, the federal government may purchase some of the supplies to be used to replenish the Strategic National Stockpile (SNS) or to provide to states with any identified and unmet needs.
• To address the anticipated ventilator shortage across the nation, the task force has implemented a similar strategy, leveraging the strengths of the commercial industry Including numerous vendors, such as General Electric, Phillips, Medtronic, Hamilton, Zoll, ResMed, Hillrom and Vyair, to produce 20,000 ventilators over the next two months with the potential to add 100,000 by end of June. This represents a significant increase in velocity as the normal annual market is 30,000 per year.
• As a reminder, to expedite purchasing, FEMA issued a request for quotation for vendors who have needed medical equipment and supplies to sell to the agency.

Admiral Brett Giroir & Surgeon General Jerome Adams Release Letter on Optimizing Ventilator Use: Last night, the Assistant Secretary of Health and US Surgeon General issued an open letter on strategies for optimizing ventilator use including use of guidance on co-venting. In the letter, they note that ventilation of two patients with one ventilator should only be considered as an absolute last resort, but for those clinicians in crisis situations, the letter outlines how ventilator splitting can be performed strictly for two patients who are both either infected or free of the virus. We know that practices like this are currently being used in some hospitals. In that vein, we strive to provide additional information to support patient-provider decision making during times of crisis standards of care. We recognize that these decisions must be made on an individual institution, care-provider, and patient level. This is a reflection of how HHS and FEMA are working with multiple partners: healthcare systems, academic institutions, professional medical societies, and the National Academies of Science, Engineering and Medicine to develop crisis standards of care strategies for ventilator support when resources are limited.

Expanding Availability of PPE and Sterilizers and Disinfectant Devices: FDA issued guidance to help expand the availability of surgical apparel for health care professionals, including gowns, hoods, and surgeon’s and patient examination gloves during the pandemic. They also released guidance to expand the availability and capability of sterilizers, disinfectant devises and air purifiers during the pandemic. The devices include those intended to make devices sterile, kill pathogens or other microorganisms and kill pathogens or microorganisms in the air. This policy reflects FDA’s commitment to ease burdens on health care providers and facilities as they face COVID-19.

CMS Granting Key Flexibilities – Worth Including Twice:  Yesterday, CMS released an array of temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 Novel Coronavirus (COVID-19) pandemic. These temporary changes will apply immediately across the entire U.S. healthcare system for the duration of the emergency declaration. The new rules allow hospitals and health systems to deliver services at other locations to make room for COVID-19 patients needing acute care in their main facility. CMS also posted a complete summary of the flexibilities provided to all physicians and clinicians to help clarify current allowable and billable practices. CMS also approved two additional Section 1135 waivers today, bringing the total of approved waivers to 40 states.

Granting Financial Relief for Medicare Providers – Worth Repeating: Over the weekend, CMS provided financial relief to Medicare providers by expanding their accelerated and advance payment program to help ensure that they have resources needed to combat COVID-19. Accelerated and advance Medicare payments provide emergency funding and addresses cash flow issues based on historical payments when there is disruption in claims submission and/or claims processing. CMS is expanding the program for all Medicare providers throughout the country during the public health emergency related to COVID-19.  The payments can be requested by hospitals, doctors, durable medical equipment suppliers and other Medicare Part A and Part B providers and suppliers.

Updating Guidance for Labs: CDC updated their laboratory guidance for handling and processing specimens associated with COVID-19 to include environmental specimen testing guidance related to procedures that concentrate viruses.

Determining if You Are At Higher Risk for Severe Illness: CDC updated their webpage for people who are at higher risk for severe COVID-19 illness.

Providing Guidance for Healthcare Professionals: CDC added to their FAQ document for healthcare professionals additional information on drugs and investigational therapies to address common questions and misperceptions on available and approved drugs to treat COVID-19. CDC also released guidelines and a decision algorithm for how to guide care advice and messages with evaluating and triaging potential patients.

Obtaining Funding from FEMA for Emergency Medical Care Activities: The FEMA COVID-19 Emergency Protective Measures Fact Sheet included a list of eligible emergency medical care activities. This fact sheet provides additional guidance related to the eligibility of emergency medical care activities as an emergency protective measure under the Emergency Declaration and any Major Disaster Declaration authorizing Public Assistance (PA) for COVID-19.

Addressing Questions on Non-Congregate Sheltering: Non-congregate sheltering may be necessary for health and medical-related needs, such as isolation and quarantine of certain populations resulting from the public health emergency. FEMA released an FAQ document on non-congregant sheltering and how states can apply to receive approval for them.

Preparing Outpatient Hemodialysis Facilities for COVID-19 Patients: CDC released updated guidance for Infection Prevention and Control for Patients with Suspected or Confirmed COVID-19 in Outpatient Hemodialysis Facilities. This information is provided to clarify COVID-19 infection prevention and control (IPC) recommendations that are specific to outpatient hemodialysis facilities. Recommendations are listed for screening and triage of patients.

Addressing Considerations for Clinical Trials: The FDA issued an updated guidance, Conduct of Clinical Trials of Medical Products during COVID-19 Pandemic, with an appendix adding questions and answers on this subject. This guidance is intended for industry, investigators and institutional review boards and was issued because we recognize that the COVID-19 pandemic may impact the conduct of clinical trials of medical products, including drugs, devices and biological products.

Granting Flexibilities to ACF Recipients: In a memo to all of their grantees, ACF shared information to assure their grantee and recipient communities that to the extent possible they will provide short-term relief for administrative, financial management, and audit requirements in their human services programs.

Ensuring Providers Can Practice at Health Centers and Free Clinics: HRSA has released information on updated Federal Tort Claims Act policies for providers in health centers and free clinics to enable them to treat patients in these settings in an effort to prevent, prepare or respond to COVID-19.

Supporting Governors in Crisis States: The President released a memo that provides additional support to Governors in Connecticut, Illinois, Massachusetts and Michigan, allowing them to use the National Guard with 100% federal support.

This document recommends practices for extended use and limited reuse of NIOSH-certified N95 filtering facepiece respirators (commonly called “N95 respirators”). The recommendations are intended for use by professionals who manage respiratory protection programs in healthcare institutions to protect health care workers from job-related risks of exposure to infectious respiratory illnesses.

Supplies of N95 respirators can become depleted during an influenza pandemic (1-3) or wide-spreadoutbreaks of other infectious respiratory illnesses.(4) Existing CDC guidelines recommend a combination of approaches to conserve supplies while safeguarding health care workers in such circumstances. These existing guidelines recommend that health care institutions:

• Minimize the number of individuals who need to use respiratory protection through the preferential use of engineering and administrative controls;
• Use alternatives to N95 respirators (e.g., other classes of filtering facepiece respirators, elastomeric half-mask and full facepiece air purifying respirators, powered air purifying respirators) where feasible;
• Implement practices allowing extended use and/or limited reuse of N95 respirators, when acceptable; and
• Prioritize the use of N95 respirators for those personnel at the highest risk of contracting or experiencing complications of infection.

This document focuses on one of the above strategies, the extended use and limited reuse of N95 respirators only; please consult the CDC or NIOSH website for guidance related to implementing the other recommended approaches for conserving supplies of N95 respirators.

There are also non-emergency situations (e.g., close contact with patients with tuberculosis) where N95 respirator reuse has been recommended in healthcare settings and is commonly practiced.(5-9) This document serves to supplement previous guidance on this topic.

Clinical diagnostic laboratories: To identify and reimburse specimen collection for COVID-19 testing, CMS established two Level II HCPCS codes, effective with line item date of service on or after March 1, 2020:

• G2023 – Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source
• G2024 – Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source

These codes are billable by clinical diagnostic laboratories.

Building on prior action to expand reimbursement for telehealth services to Medicare beneficiaries, CMS will now allow for more than 80 additional services to be furnished via telehealth. When billing professional claims for non-traditional telehealth services with dates of services on or after March 1, 2020, and for the duration of the Public Health Emergency (PHE), bill with the Place of Service (POS) equal to what it would have been in the absence of a PHE, along with a modifier 95, indicating that the service rendered was actually performed via telehealth. As a reminder, CMS is not requiring the “CR” modifier on telehealth services. However, consistent with current rules for traditional telehealth services, there are two scenarios where modifiers are required on Medicare telehealth professional claims:

• Furnished as part of a federal telemedicine demonstration project in Alaska and Hawaii using asynchronous (store and forward) technology, use GQ modifier
• Furnished for diagnosis and treatment of an acute stroke, use G0 modifier

Traditional Medicare telehealth services professional claims should reflect the designated POS code 02-Telehealth, to indicate the billed service was furnished as a professional telehealth service from a distant site. There is no change to the facility/non-facility payment differential applied based on POS. Claims submitted with POS code 02 will continue to pay at the facility rate.

There are no billing changes for institutional claims; critical access hospital method II claims should continue to bill with modifier GT.

The Appalachian Regional Commission (ARC) is carefully and continually monitoring the COVID-19 situation as it is impacting the Appalachian Region. ARC staff, who are now primarily working from home, are diligently continuing to process and administer grants, new applications, progress reports, and payment requests as they are received.

We are assisting grantees whom are unable to meet project goals or timelines due to the current situation. If you are a current ARC grantee experiencing such challenges, please email your ARC project coordinator and state program manager as soon as possible for help with needed accommodations regarding your project’s deliverables, timelines, budget, or other operations. (When emailing, please put your ARC project number in the subject line. This will make responding to your request easier).

To support the health and safety of our partners, grantees, and communities, we have also made the following adjustments:

•  We have extended the application deadline for the Appalachian Entrepreneurship Academy to March 31, 2020. Should this program, or the ARC/ORNL Summer STEM program, need to be modified further, an announcement will be made in mid-April.
• We have extended the deadline for POWER applications to April 24, 5 pm ET. Additional revisions can also be made to applications already submitted to power.arc.gov during this thirty day extension.
• We are convening the Appalachian Leadership Institute virtually through online learning modules in lieu of the upcoming field seminars scheduled for Beckley, West Virginia and Boone, North Carolina.
• We have postponed Envision Appalachia: Community Conversations for ARC’s New Strategic Plan. Our intent is to restart our strategic planning process at a time when we can gather in-person to discuss our Region’s future.

We will be posting any additional ARC operational updates on www.arc.gov/coronavirus, and in forthcoming issues of In The Region.

This is a challenging time for our communities, our Region, and our country. Please continue to check with state and federal authorities for health-related guidance and information.

The Appalachian Regional Commission has released two new tools documenting the spread of COVID-19 at the regional and county levels. The COVID-10 Cases in Appalachia map displays the current number of confirmed cases of COVID-19 in Appalachia and throughout the United States. Higher numbers of cases are marked by larger dots, while smaller numbers of confirmed cases are represented by smaller dots. By clicking on a location, users can see confirmed COVID-19 cases and any related deaths at the county level. This map is automatically updated throughout the day drawing on data collected by the Johns Hopkins University. Due to frequent changes, it is advised that users refresh their browsers often when viewing the map. As of March 26th, at 1:30 pm (ET), there were 1,686 confirmed cases in 208 Appalachian counties.

The second tool, Explore County-level Coronavirus Impact Planning is a searchable data base offering demographic data snapshots of confirmed COVID-19 cases and deaths in relation to hospital bed counts, population and businesses, and categories of people at risk for COVID-19 in each one of the nation’s counties. By hovering over each statistical icon, users can learn more about the supporting data. COVID-19 related data is updated daily.

These resources are available at https:/www.arc.gov/coronavirus

WASHINGTON, March 31, 2020 – USDA Rural Development Deputy Under Secretary Bette Brand announced that USDA is granting lenders a temporary exception to offer payment deferrals for Agency guaranteed loan programs due to the COVID-19 pandemic.

Effective immediately until September 30, 2020, lenders may offer 180-day loan payment deferrals without prior agency approval for Business and Industry Loan Guarantees, Rural Energy for America Program Loan Guarantees, Community Facilities Loan Guarantees, and Water and Waste Disposal Loan Guarantees. For additional information, see page 17721 of the March 31, 2020, Federal Register.

Questions regarding this announcement may be directed to:

• Rural Business-Cooperative Service: Aaron Morris (Aaron.Morris@usda.gov)
• Rural Housing Service: Deborah Jackson (Deborah.Jackson2@usda.gov)
• Rural Utilities Service: Darrel Lipscomb (Darrel.Lipscomb@usda.gov)

If you’d like to subscribe to USDA Rural Development updates, visit our GovDelivery subscriber page.