Rural Health Care Implications in the $2 Trillion COVID-19 Relief Legislation: The Coronavirus Aid, Relief, and Economic Security Act

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From the National Rural Health Association (NRHA)

The Senate has passed the third in a series of bills in response to COVID-19 (S. 3548/H.R. 748). The House is expected to take action on the legislation later this week. In the language, there is $127 billion to the Assistant Secretary for Preparedness and Response to include $100 billion in grants to hospitals and other Medicare and Medicaid suppliers to cover unreimbursed health care related expenses or lost revenue related to COVID-19. Additional funding includes $275 million to HRSA to support rural hospitals and critical access hospitals and telehealth, $200 million to CMS to assist nursing homes and $955 million to the Administration for Community Living to support nutrition programs and home and community-based services. Here are the Appropriations Sections in full and a Appropriations Summary. Note: This list is not exhaustive, as NRHA’s full analysis of the bill continues. Please see a list of important provisions below.  Read the full bill here.

Public Health and Social Services Emergency Fund

  • The legislation would make available $100 billion to reimburse eligible health care providers for health care-related expenses or lost revenues not otherwise reimbursed that are directly attributable to COVID-19. Eligible providers are defined as public entities, Medicare- or Medicaid enrolled suppliers and providers, and other for-profit and non-profit entities as specified by the Health and Human Services (HHS) Secretary. Funding would be on a rolling basis through “the most efficient payment systems practicable to provide emergency payment.”

Hospital Payments

  • Sec. 3719. Expansion of the Medicare Hospital Accelerated Payment Program During The COVID-19 Public Health Emergency: This section would expand, for the duration of the COVID-19 emergency period, an existing Medicare accelerated payment program. Hospitals, especially those facilities in rural and frontier areas, need reliable and stable cash flow to help them maintain an adequate workforce, buy essential supplies, create additional infrastructure, and keep their doors open to care for patients. Specifically, qualified facilities would be able to request up to a six-month advanced lump sum or periodic payment. This advanced payment would be based on net reimbursement represented by unbilled discharges or unpaid bills. Most hospital types could elect to receive up to 100 percent of the prior period payments, with Critical Access Hospitals able to receive up to 125 percent. Finally, a qualifying hospital would not be required to start paying down the loan for four months and would also have at least 12 months to complete repayment without a requirement to pay interest.

Support for Health Care Providers

  • Sec. 3211. Supplemental awards for health centers: Provides $1.32 billion in supplemental funding to community health centers on the front lines of testing and treating patients for COVID-19.
  • Sec. 3212. Telehealth network and telehealth resource centers grant programs: Reauthorizes HRSA grant programs that promote the use of telehealth technologies for health care delivery, education and health information services. Telehealth offers flexibility for patients with, or at risk of contracting, COVID-19 to access screening or monitoring care while avoiding exposure to others.
  • Sec. 3213. Rural Health Care Services Outreach, Rural Health Network Development, and Small Health Care Provider Quality Improvement Grant Programs: Reauthorizes HRSA grant programs to strengthen rural community health by focusing on quality improvement, increasing health care access, coordination of care, and integration of services. Rural residents are disproportionately older and more likely to have a chronic disease, which could increase their risk for more severe illness if they contract COVID-19.
  • Sec. 3216. Flexibility for members of National Health Service Corps during emergency period: Allows the Secretary of HHS to reassign members of the NHSC to sites close to the one which they were originally assigned, with the member’s agreement, in order to respond to the COVID-19 public health emergency.

Small Business Loans:

  • Sec. 1102. Title I – Small Business Administration loan program provides a maximum of $10 million loans. Defines eligibility as small business, 501(c) (3) non-profit, 501(c)19, or certain tribal groups with not more than 500 employees (unless there is a higher industry standard). Sec. 1106 includes loan forgiveness provisions. Borrower shall be eligible for loan forgiveness equal to the amount spent by the borrower during an 8-week period of payroll costs, interest payment on mortgage, rent or lease. Amounts forgiven may not exceed the principal amount of the loan. Eligible payroll costs do not include salaries that exceed $100,000.
  • Also waives borrower and lender fees, waives “credit elsewhere” test, and waives collateral and personal guaranteed requirements. Maximum interest rate of 4% and no pre-payment penalties Complete deferment of loan repayment is deferred by 6 months.

Telehealth:

  • Sec. 3701. Health Savings Accounts for Telehealth Services: This section would allow a high-deductible health plan (HDHP) with a health savings account (HSA) to cover telehealth services prior to a patient reaching the deductible, increasing access for patients who may have the COVID-19 virus and protecting other patients from potential exposure.
  • Sec. 3703. Expanding Medicare Telehealth Flexibilities: This section would eliminate the requirement in Coronavirus Preparedness and Response Supplemental Appropriations Act of 2020 (Public Law 116-123) that limits the Medicare telehealth expansion authority during the COVID-19 emergency period to situations where the physician or other professional has treated the patient in the past three years. This would enable beneficiaries to access telehealth, including in their home, from a broader range of providers, reducing COVID-19 exposure.
  • Sec. 3704. Allowing Federally Qualified Health Centers and Rural Health Clinics to Furnish Telehealth in Medicare: This section would allow, during the COVID-19 emergency period, Federally Qualified Health Centers and Rural Health Clinics to serve as a distant site for telehealth consultations. A distant site is where the practitioner is located during the time of the telehealth service. This section would allow FQHCs and RHCs to furnish telehealth services to beneficiaries in their home. Medicare would reimburse for these telehealth services based on payment rates similar to the national average payment rates for comparable telehealth services under the Medicare Physician Fee Schedule. It would also exclude the costs associated with these services from both the FQHC prospective payment system and the RHC all-inclusive rate calculation.
  • Sec. 3706. Allowing for the Use of Telehealth during the Hospice Care Recertification Process in Medicare: Under current law, hospice physicians and nurse practitioners cannot conduct recertification encounters using telehealth. This section would allow, during the COVID-19 emergency period, qualified providers to use telehealth technologies in order to fulfill the hospice face-to face recertification requirement.

Other Medicare Provisions:

  • Sec. 3709. Increasing Provider Funding through Immediate Medicare Sequester Relief: This section would provide prompt economic assistance to health care providers on the front lines fighting the COVID-19 virus, helping them to furnish needed care to affected patients. Specifically, this section would temporarily lift the Medicare sequester, which reduces payments to providers by 2 percent, from May 1 through December 31, 2020, boosting payments for hospital, physician, nursing home, home health, and other care. The Medicare sequester would be extended by one-year beyond current law to provide immediate relief without worsening Medicare’s long-term financial outlook.
  • Sec. 3710. Medicare Add-on for Inpatient Hospital COVID-19 Patients: This section would increase the payment that would otherwise be made to a hospital for treating a patient admitted with COVID-19 by 20 percent. It would build on the Centers for Disease Control and Prevention (CDC) decision to expedite use of a COVID-19 diagnosis to enable better surveillance as well as trigger appropriate payment for these complex patients. This addon payment would be available through the duration of the COVID-19 emergency period.
  • Sec. 3713. Eliminating Medicare Part B Cost-Sharing for the COVID-19: Vaccine This section would enable beneficiaries to receive a COVID-19 vaccine in Medicare Part B with no cost-sharing.
  • Sec. 3718. Preventing Medicare Clinical Laboratory Test Payment Reduction: This section would prevent scheduled reductions in Medicare payments for clinical diagnostic laboratory tests furnished to beneficiaries in 2021. It would also delay by one year the upcoming reporting period during which laboratories are required to report private payer data

Community Health Centers

  • Sec. 3831. Extension for Community Health Centers, the National Health Service Corps, and Teaching Health Centers that Operate GME Programs: This section extends funding for the three programs until November 20th, 2020.

Indian Health Services

  • Includes an additional $1 billion for the Indian Health Services to remain available until September 30, 2021, to prevent, prepare for, and respond to coronavirus, domestically or internationally, including for public health support, electronic health record modernization, telehealth and other information technology upgrades, Purchased/Referred Care, Catastrophic Health Emergency Fund, Urban Indian Organizations, Tribal Epidemiology Centers, Community Health Representatives, and other activities to protect the safety of patients and staff (pg. 718).

Medicaid

  • Sec. 3720. Providing State Access to Enhanced Medicaid FMAP: This section would amend a section of the Families First Coronavirus Response Act of 2020 (Public Law 116-127) to ensure that states are able to receive the Medicaid 6.2 percent FMAP increase.
  • Sec. 3801. Extension of Physician Work Geographic Index Floor: This section would increase payments for the work component of physician fees in areas where labor cost is determined to be lower than the national average through December 1, 2020.
  • Sec. 3811. Extension of Money Follows the Person Demonstration Program: This section would extend the Medicaid Money Follows the Person demonstration that helps patients transition from the nursing home to the home setting through November 30, 2020.
  • Sec. 3813. Delay of Disproportionate Share Hospital Reductions: This section would delay scheduled reductions in Medicaid disproportionate share hospital payments through November 30, 2020.
  • Sec. 3715. Providing Home and Community-based Support Services during Hospital Stays: This section would allow state Medicaid programs to pay for direct support professionals, caregivers trained to help with activities of daily living, to assist disabled individuals in the hospital to reduce length of stay and free up bed
  • Sec. 3813. A 6-month delay in Medicaid DSH cuts. The last delay would have expired May 23rd, 2020 but is delayed through November 30th, 2020.

Rural Development

  • $20.5 million in new money in rural business loans and grants through the USDA to “prevent, prepare, and respond to COVID-19”
  • $25 million to support the Distance, Learning, and Telemedicine program for rural communities for COVID-19 related care. This increase will help improve distance learning and telemedicine in rural areas of America.
  • $100 million is provided to the ReConnect program to help ensure rural Americans have access to broadband, the need for which is increasingly apparent as millions of Americans work from home across the country.

Other Public Health and Social Services Emergency Fund

  • Increasing the National Stockpile: Provides $16 billion for medical supplies to be deposited in the Strategic National Stockpile.

Hospital Preparedness Program: Provides $250 million available for grants to or cooperative agreements with entities that are either grantees or sub-grantees of the Hospital Preparedness Program authorized in section 7 319C–2 of the Public Health Service Act or that meet such other criteria as the Secretary may prescribe, with such awards issued under such section or section 311 of the act.