COVID19: CMS Waiver 1135 – Here’s what you need to know

Staying Alive and CMS Waiver 1135

A COVID-19 Managed Care Update

I hope wherever you are, you are staying safe, acting smart, and keeping strong throughout these very challenging times.

I’m going to take a tip from everybody on this platform , that is trying to help others out with information as much as possible and I’d like to give you a quick update on how Managed Care is being affected within skilled nursing facilities and the healthcare environment.

But first we must talk about Medicare and understand what changes have been put in place by CMS.

There is the 1135 waiver which was put in place to ease some of the restrictions regarding how skilled nursing facilities can treat Medicare members. For the most part the 1135 waiver allows the 3 day Qualifying Hospital Stay to go away, as well as the 60 day wellness break that’s in between benefit periods for a Medicare 100 day benefit period to also be looked aside , as long as – and this is important – as long as the resident in your facility qualifies or falls in to the category of someone who was affected by the Coronavirus. So, it cannot just be anybody, but it must be somebody that was actually affected. It does not have to be directly but can even be indirectly affected by the virus is why you are looking to continue their coverage.

Another thing that is important , because I was asked by a facility yesterday, is that if you have a Medicare member that is no longer skilled and really can be discharged or moved to a lower level payer, the 1135 waiver will not allow them to remain covered by Medicare it is only for those that have a skilled need.

And finally, there are other things that the waiver allows for regarding PDPM assessments as well as a few other things, but I would like to simplify it and just discuss this.

In regards to Managed Care we’ve spoken to many Insurance companies yesterday, and for the most part firstly understand that most of the insurers do not require a 3 day qualifying hospital stay for coverage so therefore that portion of the waiver is not really relevant.

It is important to know that as of now the pre-certification and extension process in order to maintain authorizations is staying as it is. Something to keep in mind is that there will be more likelihood of residents that will admitting from home vs. from the hospital.

Typically, the hospital will have a lot of the medical records to submit, so when you’re getting a pre-certification now from the insurance companies make sure to submit whatever medical records the resident does have. It could be their doctors note, it could be any other medical records that justify the need for them to be in a facility. And the insurance company will review that and take that into consideration.

Obviously if there is any extenuating circumstance or something that needs to be addressed because of the current situation, they will look at that and make a case by case decision.

One more request that Insurance companies had, is that if any of your residents do test positive for Corona virus, to immediately inform the insurers of any of their members that are in the facility as well. They need to be aware of this, they need to be notified and they to more this up the chain to whoever they need to notify. So please be vigilant about this, and if you have anything else to add in regard to this that i may have not mentioned, please mention it in the comments.

And in general, just like we are doing here, trying to give helpful information for those that we can help please do the same for your field and your areas of expertise. If you have any information that can help other people, now’s a great time to do it.


Steve Shain is the Chief Operating Officer of LTC Contracting.

LTC Contracting guides providers through licensure and business setup procedures and ensures compliance with all regulations, whether the providers are opening new organizations or adding new service lines to their existing businesses. LTC’s services also include getting providers credentialed and on the Managed Care Organizations’ (MCOs’) networks.