June 29th Newsletter - Sachs Policy Group

State Updates

Governor Cuomo Announces Continued COVID-19 Progress in New York State

Today (June 29^th), Governor Cuomo held a press conference during which he announced continued success in combatting the COVID-19 pandemic in New York State. Yesterday, there were 853 total hospitalizations and the three-day rolling average of deaths was 8. Of the 46,428 individuals tested for COVID-19 across the state yesterday, 391 (0.84 percent) were positive. The positive test rate in New York City remains steady at around 1 percent. Western New York is on track to enter Phase 4 of reopening tomorrow. While New York City is slated to enter Phase 3 on July 6^th, the Governor noted several potential complications that might result in a delay, including a lack of compliance with social distancing and potential spread from other states. The State will be reviewing data and consulting with relevant stakeholders to determine next steps in New York City with a final decision by Wednesday.

The Governor discussed the capabilities of air filters with a high Minimum Efficiency Reporting Value (MERV), such as High Efficiency Particulate Air (HEPA) filters, in helping to reduce the presence of COVID-19 in air filtration systems. The State is recommending that all businesses and offices consider installing filters with a MERV rating capable of filtering COVID-19.

Governor Cuomo Issues Executive Order 202.45

On June 26^th, Governor Cuomo signed Executive Order 202.45 (available here). The Order stipulates that an employee may not be entitled to legally required paid sick leave or other benefits if they voluntarily travel to a state or country with significant community spread of COVID-19. Additionally, Executive Order 202.34 is extended through July 26^th so that schools will continue to remain closed for in-person instruction except for special education.

For regions that have entered Phase 4 of the State’s reopening plan, the Order allows for the resumption of gatherings and services permitted in Phase 4 in accordance with Department of Health (DOH) guidelines related to social distancing, face coverings, and cleaning/disinfection. Phase 4 industries include higher education, film and music production, low-risk indoor and outdoor arts and entertainment, and professional sports without fans. Gatherings in Phase 4 regions may include up to 50 individuals; however, gatherings occurring indoors may not exceed 50 percent of the maximum occupancy for that particular indoor area.

DFS Issues Guidance on Resumption of Preauthorization and Concurrent/Retrospective Review

On June 26^th, the New York State Department of Financial Services (DFS) released new guidance relating to utilization review requirements suspended due to COVID-19 in Supplement No. 2 (available here) to Insurance Circular Letter No. 8. The original circular letter (available here) and its Supplement No. 1 (available here) suspended existing rules for preauthorization and concurrent/retrospective medical necessity reviews for hospital services until June 18, 2020 and provided expedited hospital claim payments.

Supplement No. 2 advises regulated insurance plans that preauthorization and concurrent/retrospective review were permitted to resume as of June 19, 2020. However, for services that were scheduled prior to but provided after June 18, 2020 for which hospitals were unable to obtain preauthorization due to the suspension, insurers are directed to implement preauthorization requirements for such services in a reasonable manner” through July 6^th. Hospitals are still directed to use best efforts to provide at least 48 hours’ notice to plans. The guidance also reminds plans that the commencement of the timeframes during which hospitals can initiate internal or external appeals are no longer being delayed.

Additionally, the guidance advises plans to continue “reasonable” policies regarding COVID-19 utilization review, including:

Upon resumption of retrospective review for inpatient and outpatient services provided at in-network hospitals on and after June 19, 2020, ensuring that documentation requirements are reasonable and recognize that DOH relaxed certain documentation requirements during the COVID-19 pandemic.
Ensuring that documentation requirements for utilization review, including retrospective review, at facilities licensed by OMH or OASAS are reasonable and take into consideration the extraordinary circumstances that existed at the time the health care services were provided.
Refraining from down-coding claims for services provided to COVID-19 patients in the absence of evidence that the hospital in engaging in intentional and inappropriate upcoming of claims.
Refraining from denying emergency department and inpatient hospital treatment provided during the state of emergency for diagnosed or suspected COVID-19 cases as not medically necessary on retrospective review.
Continuing to expeditiously resolve and pay hospital claims and work with participating hospitals to assist with cash flow issues.

Updated Guidance Documents

Recently released New York State and City guidance documents are listed below:

Federal Update

HHS Updates Provider Relief Fund FAQ

The Department of Health and Human Services (HHS) is continuing to update the FAQ document for the CARES Act Provider Relief Fund. Notable updates include:

Some providers may have been wrongly left off of their state’s list of Medicaid providers submitted to HHS, a requirement for eligibility for the $15 billion Medicaid Distribution. In such cases, HHS may use additional data to validate eligibility and may also accept amended lists from states.
The revenue from independent living units fits within the definition of “patient care” applying for the Medicaid Distribution.
In the Eligibility Portal, Medicaid Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IDDs) are categorized as “Residential Facilities” (code RF).
Providers of self-directed Home and Community-Based Services (HCBS) who receive payment from a Fiscal Intermediary are eligible to receive Provider Relief Fund money. However, the payments will only be made to a filing TIN entity on the state-submitted list or included in T-MSIS files. If the self-directed providers are not on this list, the Fiscal Intermediary may be eligible to apply on their behalf and distribute funds downstream.
If a provider is paid through a certified public expenditure, it will not impact their eligibility for the Provider Relief Fund.
Providers paid through Organized Healthcare Delivery Systems (OHCDS) are eligible to receive money from the Provider Relief Fund. However, the OHCDS has sole discretion as to how the funds are distributed.
Healthcare providers that bill for Medicaid or CHIP services through a county behavioral health provider network are eligible for the Medicaid General Distribution if they otherwise meet the other eligibility criteria.
A healthcare provider is still eligible to receive a payment from the Provider Relief Fund Medicaid Distribution if they’ve also received funding from the Small Business Administration’s Payroll Protection Program and/or the Federal Emergency Management Agency.

The full updated FAQs are available here.