Department of Health & Human Services
Centers for Medicare & Medicaid
601 East 12th Street, Room 355
Kansas City, Missouri 64106-2898
Medicaid and CHIP Operations Group
December 18, 2024
Stuart Portman, Executive Director
Medical Assistance Plans
Georgia Department of Community Health
2 Martin Luther King Jr. Drive SE
East Tower, 19th Floor
Atlanta, Georgia 30334
Re: Section 1135 Flexibilities Requested on December 12, 2024
Dear Executive Director Portman:
On September 23, 2024, the President of the United States issued a proclamation that 2024 Hurricane Helene constitutes an emergency by the authorities vested in the President by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (the Act). On September 24, 2024, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services (HHS) declared a public health emergency (PHE), invoking the authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act. During a PHE, the Centers for Medicare and Medicaid Services (CMS) may approve the use of section 1135 authority to help ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in CMS programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of September 27, 2024, with a retroactive effective date of September 24, 2024. The emergency period will terminate, and section 1135 waivers will no longer be available, upon termination of the PHE, including any extensions.
Your submission to CMS on December 12, 2024 detailed federal Medicaid requirements that pose issues or challenges for the health care delivery system in Georgia. Below, please find a response to each of your requests for waivers or modifications, pursuant to section 1135 of the Act, to address the challenges posed by 2024 Hurricane Helene. To the extent the requirements the state requested to waive or modify apply to the Children's Health Insurance Program (CHIP), the state may apply the approved flexibilities to CHIP.
We appreciate the efforts of you and your staff in responding to the needs of the residents and health care community in Georgia. Please contact your state lead if you have any questions or need additional information.
Sincerely,
Courtney Miller
Director
cc: Courtney Miller, Anne Marie Costello, Daniel Tsai
STATE OF GEORGIA
APPROVAL OF FEDERAL SECTION 1135 WAIVER REQUESTS
CMS Response: December 18, 2024
To the extent applicable, the following waivers and modifications also apply to CHIP.
Long Term Services and Supports (LTSS)
PASRR
Pursuant to section 1135(b)(5) of the Act, CMS approves a modification of Section 1919(e)(7) and 42 C.F.R. § 483.112 to allow Level I and Level II assessments to be waived by the state for 30 days from admission. After 30 days, Level I assessments should be conducted with reasonable promptness and Level II assessments should be coordinated with the resident review.
Additionally, please note that per 42 C.F.R. § 483.106(b)(4), new preadmission Level I and Level II screens are not required for residents who are being transferred between nursing facilities (NF). If the NF is not certain whether a Level I had been conducted at the resident's evacuating facility, a Level I can be conducted by the admitting facility during the first few days of admission as part of intake and transfers. Positive Level I screens necessitate a Resident Review.
Fee for Service and Eligibility Fair Hearings
Extend fair hearing request timelines
Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify requirements in 42
C.F.R. § 431.221(d) to allow applicants and beneficiaries to have more than 90 days to request a fair hearing for eligibility or fee-for-service appeals by permitting extensions of the timeline to file a fair hearing request (e.g. additional time more than 90 days). This waiver supplements the timeframe in 42 C.F.R. § 431.221(d), which requires states to choose a reasonable timeframe for individuals to request a fair hearing not to exceed 90 days for eligibility or fee-for-service appeals.
Managed Care Appeals, Fair Hearings, and Continuation of Benefits
Modify adverse benefit appeals filing timelines
Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify timeframes in 42 C.F.R. § 438.402(c)(2)(ii) to extend the time period to file an appeal from 60 to 120 days following the receipt of an adverse benefit determination to allow more time for the enrollee to file a request for an internal appeal with the managed care plan. The managed care plan will continue to authorize and pay for the service(s) until a decision is made and may not seek reimbursement or payment for the services furnished during this additional period (other than otherwise applicable cost sharing, if any) from the enrollee in the event of an adverse decision. For example, the timeframe extension from 60 to 120 will allow the enrollee more time to effectively utilize the managed care plan’s appeal process. This ensures the enrollees continued access to services extension period and does not impact the enrollee’s right to fair hearing should they exhaust the plan’s appeal process.
Provider Enrollment
With respect to providers not already enrolled with another State Medicaid Agency (SMA) or Medicare, pursuant to section 1135(b)(1) and (b)(2) of the Act, CMS waives the following screening requirements: application fees, criminal background checks, licensing requirements, and site visits, so the state may provisionally, temporarily enroll the providers for the duration of the PHE.
CMS is granting this waiver authority to allow the state to temporarily enroll providers who are not currently enrolled with another SMA or Medicare so long as the state meets the following minimum requirements:
- Must collect minimum data requirements in order to file and process claims, including, but not limited to NPI.
- Must collect Social Security Number, Employer Identification Number, and Taxpayer Identification Number (SSN/EIN/TIN), as applicable, in order to perform the following screening requirements:
a. OIG exclusion list
b. State licensure – provider must be licensed, and legally authorized to practice or deliver the services for which they file claims, in at least one state/territory - The state must also:
a. Issue no new temporary provisional enrollments after the date that the PHE is lifted,
b. Cease payment to providers who are temporarily enrolled within six months from the termination of the PHE, including any extensions, unless a provider has submitted an application that meets all requirements for Medicaid participation and that application was subsequently reviewed and approved by the state before the end of the six-month period after the termination of the PHE, including any extensions, and
c. Allow a retroactive effective date for provisional temporary enrollments that is no earlier than September 24, 2024.
Clinic Facility Requirement
Allow provision of clinic services via telehealth
Pursuant to section 1135(b)(1)(B) of the Act, CMS approves a waiver to permit the state and clinic to temporarily designate a clinic practitioner’s location as part of the clinic facility only to the extent necessary so that clinic services may be provided via telehealth when neither the patient nor practitioner is physically onsite at the clinic. Services provided via telehealth in clinic practitioners’ homes (or another location) will be considered to be provided at the clinic. - 42 C.F.R. § 440.90(a)
Allow provision of clinic services in alternative settings
Pursuant to section 1135(b)(1)(B) of the Act, CMS approves a waiver allowing the state and clinic to temporarily designate a clinic practitioner’s location as part of the clinic facility in order to ensure access to health services that would otherwise be unavailable during the PHE. This waiver is provided only to the extent necessary so that clinic services may be delivered when neither the patient nor practitioner is physically onsite at the clinic. The waiver permits services provided in The Georgia Department of Community Health is requesting that alternative service locations be authorized as follows: (1) shelters, (2) schools, (3) churches, (4) family/member's home, (5) or other emergency location as deemed appropriate by the State Medicaid Agency. This flexibility only applies to providers located within the counties impacted by Hurricane Helene. The counties are as follows: Appling, Atkinson, Bacon, Baldwin, Ben Hill, Berrien, Bleckley, Brantley, Brooks, Bryan, Bullock, Burke, Butts, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Colquitt, Columbia, Cook, Echols, Effingham, Elbert, Emanuel, Evans, Glascock, Glynn, Hancock, Irwin, Jeff Davis, Jefferson, Jekins, Johnson, Lanier, Laurens, Liberty, Lincoln, Long, Lowndes, Madison, McDuffie, McIntosh, Montgomery, Newton, Pierce, Putnam, Rabun, Richmond, Screven, Taliaferro, Tattnall, Telfair, Tift, Toombs, Treutlen, Turner, Ware, Warren, Washington, Wayne, Wheeler, Wilkes, Wilkinson, and Worth. to be considered as provided at the clinic for purposes of 42 C.F.R. § 440.90(a).
STATE OF GEORGIA
FEDERAL SECTION 1135 WAIVER REQUESTS UNDER REVIEW
CMS Response: December 18, 2024
To the extent applicable, the following waivers and modifications also apply to CHIP.
Please see below for the items that remain under CMS review.
Waiver or Suspension of Prior Authorization Requirements
The Georgia Department of Community Health is requesting authority to temporarily suspend Medicaid fee-for-service/managed care prior authorization requirements for providers located in the counties of the state impacted by Hurricane Helene. The counties are as follows: Appling, Atkinson, Bacon, Baldwin, Ben Hill, Berrien, Bleckley, Brantley, Brooks, Bryan, Bullock, Burke, Butts, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Colquitt, Columbia, Cook, Echols, Effingham, Elbert, Emanuel, Evans, Glascock, Glynn, Hancock, Irwin, Jeff Davis, Jefferson, Jekins, Johnson, Lanier, Laurens, Liberty, Lincoln, Long, Lowndes, Madison, McDuffie, McIntosh, Montgomery, Newton, Pierce, Putnam, Rabun, Richmond, Screven, Taliaferro, Tattnall, Telfair, Tift, Toombs, Treutlen, Turner, Ware, Warren, Washington, Wayne, Wheeler, Wilkes, Wilkinson, and Worth. Section 1135(b)(1)(C) allows for a waiver or modification of pre-approval requirements, including prior authorization processes required under the State Plan for particular benefits. Prior authorization and medical necessity processes in fee-for-service delivery systems are established, defined and administered at state/territory discretion and may vary depending on the benefit.
Request to modify the timelines and deadlines for providers to respond to RAC audits and the timelines and deadlines for the State Medicaid Agency's RAC auditor to request records
The Georgia Department of Community Health is requesting authority to modify the timelines and deadlines for providers to respond to RAC audit requests. This will allow providers additional time to provide requested information post the conclusion of the Public Health Emergency. This waiver will also authorize the State Medicaid Agency and its RAC vendor the authority to modify the timelines and deadlines for conducting its RAC audit reviews.
Extend Pre-Existing Prior Authorizations
Extend pre-existing authorizations for which a beneficiary has previously received prior authorization through the end of the public health emergency. This allows services to continue to be provided without a requirement for a new or renewed prior authorization, through the termination of the public health emergency, including any extensions (up to the last day of the emergency period under section 1135(e) of the Act), for beneficiaries with a permanent residence in the geographic area of the public health emergency declared by the Secretary. This only applies to providers located within the counties impacted by Hurricane Helene. The counties are as follows: Appling, Atkinson, Bacon, Baldwin, Ben Hill, Berrien, Bleckley, Brantley, Brooks, Bryan, Bullock, Burke, Butts, Camden, Candler, Charlton, Chatham, Clinch, Coffee, Colquitt, Columbia, Cook, Echols, Effingham, Elbert, Emanuel, Evans, Glascock, Glynn, Hancock, Irwin, Jeff Davis, Jefferson, Jekins, Johnson, Lanier, Laurens, Liberty, Lincoln, Long, Lowndes, Madison, McDuffie, McIntosh, Montgomery, Newton, Pierce, Putnam, Rabun, Richmond, Screven, Taliaferro, Tattnall, Telfair, Tift, Toombs, Treutlen, Turner, Ware, Warren, Washington, Wayne, Wheeler, Wilkes, Wilkinson, and Worth.