Section 1135 Waiver Flexibilities - Puerto Rico 2019 Earthquake Pubic Health Emergency

Department of Health & Human Services
Centers for Medicare & Medicaid Services
26 Federal Plaza, Room 37-100
New York, New York 10278

January 8, 2020

Luz E. Cruz-Romero
Executive Director, PR Medicaid Program
Department of Health
PO Box 70184
San Juan, PR 00936-8184

Dear Ms. Cruz-Romero:

The Secretary of the Department of Health and Human Services, Alex Azar, has declared a public health emergency for Puerto Rico, and has authorized the Centers for Medicare & Medicaid Services to exercise authority under section 1135 of the Social Security Act to waive certain requirements of the Medicare, Medicaid and Children’s Health Insurance programs during the emergency period. We are writing this letter to inform Puerto Rico of the various provider enrollment flexibilities that will enable Puerto Rico to administer its Medicaid program after the effects of the earthquakes.

Puerto Rico Medicaid Provider Enrollment Disaster Relief

Puerto Rico currently has the authority to rely upon screening that is performed by other State Medicaid Agencies (SMAs) and/or Medicare. Puerto Rico is not required to create a temporary provisional enrollment for providers who are enrolled with another SMA or Medicare.

With respect to providers not already enrolled with another SMA or Medicare, CMS will waive the following screening requirements so the state/territory may provisionally, temporarily, enroll the providers:

1. Payment of the application fee - 42 C.F.R 455.460
2. Criminal background checks associated with FCBC- 42 C.F.R Section 455.434
3. Site visits - 42 C.F.R Section 455.432
4. In-state/territory licensure requirements - 42 C.F.R Section 455.412

For those providers located out of state/territory and from which Puerto Rico Medicaid participants seek care, enrollment is not necessary if the following criteria are met:

1. 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,
2. The NPI of the furnishing provider is represented on the claim,
3. The furnishing provider is enrolled and in an “approved” status in Medicare or in another state/territory’s Medicaid plan,
4. The claim represents services furnished, and;
5. The claim represents either:
   1. A single instance of care furnished over a 180 day period, or
   2. Multiple instances of care furnished to a single participant, over a 180 day period

If the Medicaid participant is enrolled with the Medicaid program from the disaster designated state, the final two criterion will be waived. Therefore, there is no limit to the instances of care furnished or to how many participants in a 180-day period.

In the instance that a certified provider is enrolled in Medicare or with a state/territory’s Medicaid program other than Puerto Rico, Puerto Rico may perform an expedited enrollment, as described above, of an out-of-state/territory facility in order to accommodate participants who were displaced by the disaster.

CMS is granting waiver authority to allow Puerto Rico to enroll providers who are not currently enrolled by meeting the following minimum requirements:

1. Must collect minimum data requirements in order to file claims and process, including, but not limited to NPI
2. Must collect SSN/EIN/TIN in order to perform the following screening requirements:
   1. OIG exclusion list
   2. State/territory licensure – provider must be licensed, and legally authorized, in any state/territory to practice or deliver the services for which they intend to file claims
3. Puerto Rico may grant a provisional temporary enrollment that meets the following requirements:
   1. Must cease approving temporary provisional enrollments no later than the date that the disaster designation is lifted
   2. Must cease payment to providers who are temporarily enrolled within six months from the date that the disaster designation is lifted, unless a provider has submitted an application that meets all requirements for Medicaid participation and that application was subsequently reviewed and approved by Puerto Rico.
   3. Puerto Rico must allow a retroactive effective date for provisional temporary enrollments that is no earlier than December 28, 2019.

Puerto Rico may temporarily cease revalidation of providers who are located in Puerto Rico or are otherwise directly impacted by the disaster. These provider enrollment disaster relief efforts also apply to the Children’s Health Insurance Program (CHIP). 

If you have any questions related to the information provided in this letter or need additional guidance, CMS is available to provide technical assistance.

Sincerely,

Nicole McKnight
Acting Deputy Director