Department of Health & Human Services
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850
April 7, 2020
Department of Human Services
1303 Hospital Ground
Knud Hansen Complex, Building A
St. Thomas, U.S. Virgin Islands 00802
Re: Section 1135 Flexibilities Requested in April 2, 2020 Communication
Dear Director Smith:
On March 13, 2020, the President of the United States issued a proclamation that the COVID-19 outbreak in the United States constitutes a national emergency by the authorities vested in him 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 (Act). On March 13, 2020, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services invoked his authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act as a result of the consequences of the COVID-19 pandemic, to the extent necessary, as determined by the Centers for Medicare & Medicaid Services (CMS), to ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in the respective 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 as a result of the COVID-19 pandemic, 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 6PM Eastern Standard Time on March 15, 2020, with a retroactive effective date of March 1, 2020. The emergency period will terminate, and section 1135 waivers will no longer be available, upon termination of the public health emergency, including any extensions.
Your communication to CMS on April 2, 2020, detai1ed a number of federal Medicaid requirements that pose issues or challenges for the health care delivery system in all counties in the U.S Virgin Islands and requested a waiver or modification of those requirements. Attached, please find a response to your requests for waivers or modifications, pursuant to section 1135 of the Social Security Act, to address the challenges posed by COVID-19. This approval addresses those requests related to Medicaid, Medicare and the Children’s Health Insurance Program (CHIP).
To streamline the section 1135 waiver request and approval process, CMS has issued a number of blanket waivers for many Medicare provisions, which primarily affect requirements for individual facilities, such as hospitals, long term care facilities, home health agencies, and so on. Waiver or modification of these provisions does not require individualized approval, and, therefore, these authorities are not addressed in this letter. Please refer to the current blanket waiver issued by CMS.
CMS continues to work on the additional waiver or modification requests that are not currently reflected in the attached approval. For those waiver or modification requests that require approval under authority other than section 1135, such as under applicable regulations, through an amendment to the state plan, or through a section 1115 demonstration, my staff will continue to work with your team to review and make determinations regarding approval as quickly as possible.
Please contact Jackie Glaze, Deputy Director, Medicaid and CHIP Operations Group, at (404) 387-0121 or by email at Jackie.Glaze@cms.hhs.gov if you have any questions or need additional information. We appreciate the efforts of you and your staff in responding to the needs of the residents of the U.S. Virgin Islands and the health care community.
Deputy Administrator and Director
THE UNITED STATES VIRGIN ISLANDS
APPROVAL OF FEDERAL SECTION 1135 WAIVER REQUESTS
CMS Response: April 7, 2020
Temporarily suspend Medicaid fee-for-service prior authorization requirements. 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. See 42 C.F.R. §440.230(d). The U.S. Virgin Islands may have indicated in its approved state plan specific requirements about prior authorization processes for benefits administered through the fee-for-service delivery system. We interpret prior authorization requirements to be a type of pre-approval requirement for which waiver and modification authority under section 1135(b)(1)(C) of the Act is available.
Extend pre-existing authorizations for which a beneficiary has previously received prior authorization through the end of the public health emergency.
If prior authorization processes are outlined in the U.S. Virgin Islands’ state plan for particular benefits, CMS is using the flexibilities afforded under section 1135(b)(1)(C) of the Act that allow for waiver or modification of pre-approval requirements to permit services approved to be provided on or after March 1, 2020, 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.
State Fair Hearing Requests and Appeal Timelines
The U.S. Virgin Islands requested flexibility to temporarily delay scheduling of Medicaid fair hearings and issuing fair hearings decisions during the emergency period. CMS approves a waiver under section 1135 that allows enrollees to have more than 90 days, up to an additional 120 days for an eligibility or fee for service appeal to request a fair hearing. The timeframes in 42 C.F.R. §431.221(d) provides that states can choose a reasonable timeframe for individuals to request a fair hearing not to exceed 90 days for eligibility or fee-for-service issues.
The U.S. Virgin Islands currently has the authority to rely upon provider screening that is performed by other State Medicaid Agencies (SMAs) and/or Medicare. As a result, the U.S. Virgin Islands is authorized to provisionally, temporarily enroll providers who are enrolled with another SMA or Medicare for the duration of the public health emergency.
Under current CMS policy, as explained in the Medicaid Provider Enrollment Compendium (PDF, 586.81 KB) (7/24/18), at pg. 42, the U.S. Virgin Islands may reimburse otherwise payable claims from out-of-state providers not enrolled in the U.S. Virgin Islands’ Medicaid program if the following criteria are met:
- The item or service is furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state/territory practice location– i.e., located outside the geographical boundaries of the reimbursing state/territory’s Medicaid plan,
- The National Provider Identifier (NPI) of the furnishing provider is represented on the claim,
- The furnishing provider is enrolled and in an “approved” status in Medicare or in another state/territory’s Medicaid plan,
- The claim represents services furnished, and;
- The claim represents either:
- A single instance of care furnished over a 180-day period, or
- Multiple instances of care furnished to a single participant, over a 180-day period
For claims for services provided to Medicaid participants enrolled with the U.S. Virgin Islands’ Medicaid program, CMS will waive the fifth criterion listed above under section 1135(b)(1) of the Act. Therefore, for the duration of the public health emergency, The U.S. Virgin Islands may reimburse out-of-state providers for multiple instances of care to multiple participants, so long as the other criteria listed above are met.
If a certified provider is enrolled in Medicare or with a state Medicaid program other than the U.S. Virgin Islands, the U.S. Virgin Islands may provisionally, temporarily enroll the out-of-state provider for the duration of the public health emergency in order to accommodate participants who were displaced by the emergency.
With respect to providers not already enrolled with another SMA or Medicare, CMS will waive the following screening requirements under 1135(b)(1) and (b)(2) of the Act, so the state may provisionally, temporarily enroll the providers for the duration of the public health emergency:
- Criminal background checks associated with Fingerprint-based Criminal Background Checks - 42 C.F.R. §455.434
- Site visits - 42 C.F.R. §455.432
- In-state/territory licensure requirements - 42 C.F.R. §455.412
CMS is granting this waiver authority to allow the U.S. Virgin Islands to 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:
- OIG exclusion list
- 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 U.S. Virgin Islands must also:
- Issue no new temporary provisional enrollments after the date that the emergency designation is lifted,
- Cease payment to providers who are temporarily enrolled within six months from the termination of the public health emergency, 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 U.S. Virgin Islands before the end of the six month period after the termination of the public health emergency, including any extensions, and
- Allow a retroactive effective date for provisional temporary enrollments that is no earlier than March 1, 2020.
Under section 1135(b)(1)(B), CMS is also approving the U.S. Virgin Islands’ request to temporarily cease revalidation of providers who are located in the U.S. Virgin Islands or are otherwise directly impacted by the emergency.
These provider enrollment emergency relief efforts also apply to the Children’s Health Insurance Program (CHIP) to the extent applicable.
Duration of Approved Waivers
Unless otherwise specified above, the section 1135 waivers described herein are effective March 1, 2020 and will terminate upon termination of the public health emergency, including any extensions. In no case will any of these waivers extend past the last day of the public health emergency (or any extension thereof).