Dear Benchmarks' Members, 

We have a few updates that have come in this evening from DHHS and LME/MCOs and wanted to be sure to share with you!

Take care of each other and stay safe and healthy!

The Benchmarks' Team
See below for two letters sent by Secretary Cohen to CMS.
In addition, we have received the following emails from DHHS this evening:

Increase in Therapeutic Leave Days for ICF/IDD Facilities Due to COVID-19
Effective March 10, 2020, through the conclusion of the North Carolina declared state of emergency related to the COVID-19 crisis, NC Medicaid is temporarily increasing the number of therapeutic leave days for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF-IIDs) from 60 days to 90 days and waiving the requirement of approval needed more than 15 consecutive days per Clinical Coverage Policy 8E.
 
At the time of the initiation of the extended leave request the provider should document the leave in the record and confirm with the beneficiary/guardian the intent to return to the facility and any specific instructions related to meeting the IDD and physical health care needs of the beneficiary. The provider should check in with the beneficiary/guardian at least every 15 days and document this check in the record in to ensure the beneficiary's needs are still being met and that there is still an intent to return the facility. 
 
 
Family Support
The North Carolina Department of Health and Human Services is mailing a letter to Medicaid and NC Health Choice beneficiary households with information on COVID-19. These 1.2 million letters will be mailed in batches through April 22, 2020. Attached is a template for the letter so our partners are aware of the information and resources being shared with beneficiaries.

Thank you for your partnership in serving the citizens of North Carolina. Please send any questions to  Medicaid.COVID19@dhhs.nc.gov

Tomorrow
Joint NC DMHDDSAS and DHB (NC Medicaid) COVID-19 Update
for NC Providers

Thursday, April 16, 2020
3:00 p.m.
 
Participant Information

Register Here:

After registering, you will receive a confirmation email containing information about joining the webinar.
 
  Please feel free to share with other providers in your network or catchment area!
 
During this call, you will receive updates from DMHDDSAS and DHB representatives followed by an open Q&A session.  IN addition to DMHDDSAS and DHB subject matter experts we will also have a representative from DHSR on the call to answer questions you might have.  

In consideration of the limited time we have on the call, we ask that you review the guidance link (below) on the DHHS website and FAQs on the NC Medicaid site to see if an answer to your question has already been provided.
 
As things continue to change and move quickly during the COVID-19 pandemic, please continue to stay abreast of emerging issues, guidance by visiting:


Enhanced Substance Abuse Providers 
 
COVID-19 Guidance for Substance Abuse Intensive Outpatient Program (SAIOP) and Substance Abuse Comprehensive Outpatient Treatment (SACOT) Services

Trillium is working with the North Carolina Department of Health and Human Services (NC DHHS) on service specific guidance in response to the COVID-19 pandemic. The North Carolina Division of Health Benefits (DHB) coordinated with the Center for Medicare and Medicaid Services (CMS) and requested waivers that support flexibility in service delivery that both protects the public and ensures our most vulnerable citizens are able to continue receive support for their Behavioral Health and I/DD needs.
 
This guidance is in place retroactive to March 10, 2020 and will continue for the duration of the declared state of emergency or until further notice or amendment. Trillium may require at some future point replacement claims to add modifiers to service codes used for billing during this event; however, until that time providers should bill the existing codes until further notice. All service notes during this time must include the following statement: This service was delivered during the COVID-19 State of Emergency requiring social distancing.
 
Trillium is implementing the following changes under the Trillium Telemedicine Policy for State and Medicaid-funded Members. Providers can start IMMEDIATELY using telemedicine approaches included below for all members who have active authorizations or receive unmanaged visits for the following services:
  •   Substance Abuse Intensive Outpatient Program (SAIOP); and
  •   Substance Abuse Comprehensive Outpatient Treatment (SACOT)
DEFINITIONS:
TELEPSYCHIATRY SUBSET OF TELEMEDICINE: The term describes the delivery of psychiatric assessments and on-going care through the use of two-way, real time-interactive audio and video (e.g., webcam) communication between a member, located at a distant site, and a psychiatrist, located at an alternative provider site. It is intended to overcome geographical barriers, connecting users who are not in the same physical location. This is inclusive of telephonic assessment, screenings, or follow up visits.
 
TELEBEHAVIORAL HEALTH SUBSET OF TELEMEDICINE: The term describes the delivery of diagnostic assessments and on-going care through the use of two-way, real time-interactive audio and video (e.g., webcam) communication between a member, located at a distant site, and a licensed clinician, located at an alternative provider site. It is intended to overcome geographical barriers, connecting users who are not in the same physical location. For the purposes of this policy, this is also inclusive of telephonic visits for assessment, treatment planning, therapy, and enhanced service delivery during a State of Emergency related to natural disaster or pandemic.
 
ORIGINATING SITE: The site at which the member/patient is located when receiving services. This can be the member's home (private residence or group living situation), other community location, or a health care facility when the health care provider is at a distant site.
 
DISTANT SITE: The site at which the practitioner delivering the service is located at the time the service is provided. This could be one of the following: An inpatient hospital; a crisis stabilization unit; an outpatient mental health clinic; the individual or group network provider's office; or other setting. The federal term for the Distant Site is "hub". During a declaration of a State Emergency, per guidance from NC Medicaid, any staff initiating telemedicine services from their home will bill from the primary office location.
 
REQUIREMENTS:
a.     All approved prescribers including MD/DO, Family Nurse Practitioners, and Physicians assistants must possess a valid North Carolina license and must be located within the United States.
b.     All approved credentialed staff must hold an active NC license or certification, including PhD Psychologists, LPA, LMFT, LCSW, LCMHC, LCAS, BCBA, CSAC, and/or RN. Also includes any Associate level licensure categories associated with these licensed professionals. All provider staff providing telemedicine services must practice within their scope of license or certification.
c.      Treatment Planning and Consultation: A psychiatrist providing telemedicine services must be available to members of the treatment team for consultation and planning regarding any specific evaluative or treatment services rendered during the telemedicine encounter; but it is not required to be available on an ongoing basis to the treatment team.

During this declared State of Emergency by North Carolina's Governor, this telemedicine policy will include the provision of enhanced services, with Mental Health and/or Substance Use Disorder that do not require licensure. For I/DD services RB-BHT is included as a part of this covered service array. This telemedicine policy will also cover virtual services (telephonic or virtual service secure portal) delivery by non-licensed staff (qualified professionals, paraprofessionals, Board Certified Behavior Analyst and Registered Behavior Technician under the supervision of a BCBA, and certified peer support specialists), as appropriate per typical service delivery under Clinical Coverage Policy.
 
TECHNICAL SERVICES/EQUIPMENT/ENVIRONMENTAL REQUIREMENTS SHALL INCLUDE:
a.     Shall be based on member needs and equipment available and may include telephonic service delivery or virtual/video conferencing services delivery.
b.     For virtual services delivery the platform used should be HIPAA compliant (see HHS Office of Civil Rights guidance at    https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html) .
c.     Evaluation and/or treatment performed in an environment where there is a reasonable expectation of absence of intrusion by individuals not involved in the member's direct care.
 
SIGNAL RECOVERY:
a.     In the event of a loss of the internet-based video telecommunications signal, the member and the Distant Site provider should communicate by telephone.
b.     Both sides should attempt to make system corrections.
c.     If the video connection cannot be reestablished, the telephone may be used to continue the encounter if appropriate for the given clinical situation.
 
CONSENT
a.    Explicit oral informed consent for telehealth must be obtained and documented in the patient chart.
b.    The consent must explicitly state that the member has been provided with the options of telemedicine or face-to-face assessment by a clinician at a later date upon request.
c.    The consent must clearly indicate that the member has decided to receive telemedicine services rather than the other alternatives.
d.    Consent should include permission from the member to have others in the room when necessary for purposes of safety and/or health concerns or when developmental delays require input from caregivers
e.    The consent must clearly state that the member can terminate the agreement to receive telemedicine services at any time.
f.     Prior to each session a review of service options must be provided and a verbal confirmation of the member's wish to receive Telemedicine services must be documented. The clinician must document the verbal consent.
g.    Video and audio transmission shall not be retained in any medium, including the clinical record, unless there is the consent of the member or guardian. Specific mention of the retention of this transmission will be required on any consent form approved for this purpose.
h.    All consents for treatment and other procedures applicable to face-to-face encounters must be obtained for telemedicine encounters.
 
RESPONSIBILITY AND REQUIREMENTS OF STAFF INVOLVED WITH TELEMEDICINE
 
ENCOUNTER
a.     The clinician will minimize distractions during the video teleconferencing encounters in order to facilitate trust and rapport with the member.
b.     The clinician will speak the language of the member whenever possible. When not possible, an interpreter will be utilized in the same manner as those used in face-to-face treatment.
c.     The clinician will participate in treatment planning and consultation regarding members with members of the treatment team to the same extent as the other clinician and service providers.
d.         If medication is prescribed, the clinician will ensure timely transmission of prescriptions and verbal orders to pharmacies or input into the Electronic Medical Record if available .
 
SERVICE REQUIREMENTS:
a.      Review of Records: Applicable records from a remote site should be sent in advance of telemedicine encounters when possible for existing members.
b.     History: Relevant updates to psychiatric, developmental, social, medical, and substance use/abuse histories may be obtained during the telemedicine encounter.
c.      Mental Status: Relevant mental status exam may be obtained via the telemedicine encounter. This will include a series of questions to find out if a person is oriented to time, date, and place, and is the person's speech logical and coherent. The intent is to be sure the person is able to appropriately engage in the telemedicine appointment and they don't need a different type of intervention
d.     Laboratory Examination: The clinician should have access to all laboratory examinations and results necessary for assessment of the member as clinically indicated.
e.      Psychotherapy: The clinician should ensure that proper conditions exist for the engagement of the client and significant others in any form of psychotherapy that is undertaken during the telemedicine encounter.
f.       Enhance Service Delivery: The treatment team should ensure proper conditions exist for engagement of the member in the service being delivered through telemedicine.
g.   Emergency General Medical Treatment: When indicated by results of telemedicine examination, the clinician must have the capacity to signal for crisis and/or paramedical support and to arrange transport to a general medical emergency room

Partners Provider Alert: COVID-19 #18 - Appendix K Retainer Payment Requests
 
Appendix K Retainer Payment Requests  
 
On April 6, 2020, the Centers for Medicare and Medicaid Services (CMS) approved the Appendix K Emergency Preparedness and Response Waiver Request submitted by the NC Department of Health and Human Services (NC DHHS) on March 13, 2020. This approval permits, as requested in Appendix K, specific flexibilities and/or exceptions to the Home and Community Based Service waivers, including Innovations.
 
Partners appreciates the close collaboration with our provider network to ensure that the network is stable and available to care for the members we share. In an effort to ensure retention of direct support professionals and avoid disruption of the service system, Innovations Waiver providers will be able to request retainer payments for direct care workers during the COVID-19 pandemic. Please note that Innovation Waiver provider agencies and Employer(s) of Record are encouraged to pay staff their current pay rate even in situations when staff are not able to deliver services due to COVID-19 emergency related issues.
 
Information regarding Retainer Payments:
  •  Appendix K language states that
    • Retainer payments can be dispersed to direct care workers to address emergency related issues.
    • Retainer payments cannot be provided for more than 30 consecutive days. There can be multiple 30-day periods, however, there must be one day between each 30-day period.
    • The State confirms that retainer payments are for direct care providers who normally provide services that include habilitation and personal care but are currently unable to so due to complications experienced during the COVID-19 pandemic because the waiver participant is sick due to COVID-19 (symptomatic but does not require a positive test result); or the waiver participant is sequestered (per the State Stay at Home order) and/or quarantined based on local, state, federal and/or medical requirements/orders. The state will implement a distinguishable process to monitor payments to avoid duplication of billing.
    • Staff retainer payments may only be made for Innovations Waiver services as authorized in the Individual Service Plan (ISP) on March 13, 2020.Retainer payments are for primary staff that provide regularly scheduled services and are unable to deliver services. Staff members that are identified as back up staff are not eligible for retainer payments.
    • The only services that are available for retainer payments are services that include personal care or habilitation. These services are:
      • Community Living and Supports
      • Community Networking
      • Day Supports
      • Residential Supports
      • Supported Living
      • Supported Employment.
    • Relatives as Direct Support Employees (RADSEs) who were providing services on or before March 13, 2020 are eligible for retainer payments.
    • Providers and members may utilize retainer payments because of state of emergency requirements, staff sickness, staff unavailable due to caring for sick family member and/or member sickness, sickness in the member's home, or the need to limit staff from coming into member homes and creating health and safety concerns due to member's increased risk of sickness.
    • When a provider secures LME-MCO approval of retainer payment(s), a retainer agreement is implemented between the provider agency and the employee and will include the following statement: "The employee who is being retained will not be eligible for unemployment for the specific hours in the agreement."
    • The retainer agreement will be approved on a 30-day approval period. The retainer agreement will be reviewed in 30-day intervals to assess the continued appropriateness of the retainer agreement. If the agreement needs to be extended after the 30-day authorization period, another agreement will be implemented with a new 30-day effective period.
    • Retainer payments can not add up to more than the total number of hours per service approved in the Innovation member's ISP on March 13, 2020.
  Procedures for the Provider Agency to Follow:
  1. When the waiver participant/primary caregiver or the hired employee notifies the LME-MCO that the hired employee cannot provide the care, a retainer payment agreement may be initiated for a 30-day period or until such a time that the staff has returned to work
  2. Provider agencies and EOR(s) shall maintain documentation (as usual) via the required service grid by entering COVID-19 on the grid with the Qualified Professional's signature/EOR signature and date. COVID-19 billing must include the CR and XU Modifier.
  3. This shall be effective beginning March 13, 2020 and will end when the member is again available for services following the COVID-19 emergency.
  4. Provider agencies and EOR(s) will submit the following information to Partners every Monday for the previous week, using the form available at https://providers.partnersbhm.org/covid-19-provider-forms/. The form can be completed for each member affected or multiple members may be listed on the same form. Please note that: 
    • All components of the form need to be completed and submitted
    • Providers cannot bill for these services on top of the retainer payments indicated on the form
    • Multiple members can be included from the provider organization on the same form.
    • This form will serve as an invoice.
  5. By day 25 of the retainer approval, the Provider Agency will conduct a reassessment of continuation of the retainer agreement by assessing the following:
    a. The ongoing unavailability of the employee
    b. The health progression of the waiver participant or family
  6. When the retainer agreement is implemented because the employee is sick with the coronavirus, or if the employee has to take care of a sick family member due to symptoms of the coronavirus, the provider will assist the member/family with securing alternative staff.
If you have any immediate questions regarding payments, please contact Sandra Lewis,  slewis@partnersbhm.org and for questions regarding other flexibilities in Appendix K, please submit to InnovationsExceptions@partnersbhm.org

COVID-19 Updates
 
Cardinal Innovations is committed to supporting our network of providers and NC Medicaid. We are working together to ensure that our members continue to receive services during the novel coronavirus (COVID-19) outbreak.
 
Health Care Providers & Facilities: COVID-19 Screening and Reporting Process
As the number of persons diagnosed with or exposed to COVID-19 in North Carolina continues to increase, we are taking a number of steps to ensure that we have access to the most accurate, timely data to inform our operations and keep our members and provider safe and well. 
 
The following process outlines our expectations for all health care providers contracted by Cardinal Innovations regarding screening and reporting of all instances of COVID-19 exposure and suspected or confirmed COVID-19 diagnosis.   Read more.
 
Updates on Programs and Services
Please inform us in advance if you are experiencing capacity issues or make any changes to your services or operations to ensure that our members receive needed services. You can contact your  Network Specialist, call the provider line: 855-270-3327.
 
Masks for N.C. Health Care Providers
 Supreme Corporation, a North Carolina-based textile company, is supporting our state's health care clinicians by manufacturing N95 and KN95 masks. They anticipate to have a supply of 200,000 masks by the end of this week. Community Care of North Carolina (CCNC) staff contacted Supreme Corporation in regard to obtaining this personal protective equipment and, as of April 10, they quoted the following mask costs: $4.76 for N95 and $3.20 for KN95.
 
Orders are being taken on a first-come, first-served basis. For more information, or to order, contact Alex Bailey, Business Development Manager, at sales1@supremecorporation.com.
 
Non-Congregate Sheltering 
North Carolina has received approval from FEMA to provide sheltering alternatives, such as hotels, motels and dormitories, for North Carolinians with no other safe place to who need to quarantine or isolate in response to COVID-19 or are at high-risk for severe illness from COVID-19. The non-congregate sheltering page on the DHHS website has guidance and information about the FEMA reimbursement for this work.  Read more.
 
Frequently Asked Questions
We are actively cataloging questions from our provider network and hosting 45-minute virtual Provider Huddles to discuss developments related to providing care during the COVID-19 pandemic. Read   FAQs, including questions and answers from past Provider Huddles. [last updated April 6]