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COVID-19 Emergency Declaration Blanket Waivers for 

Health Care Providers

The Trump Administration is taking aggressive actions and exercising regulatory flexibilities to 

help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19). 

CMS is empowered to take proactive steps through 1135 waivers as well as, where applicable, 

authority granted under section 1812(f) of the Social Security Act (the Act) and rapidly expand 

the Administration’s aggressive efforts against COVID-19. As a result, the following blanket 

waivers are in effect, with a retroactive effective date of March 1, 2020 through the end of 

the emergency declaration. For general information about waivers, see Attachment A to 

this document. These waivers DO NOT require a request to be sent to the 

1135waiver@cms.hhs.gov mailbox or that notification be made to any of CMS’s 

regional offices.

Hospitals, Psychiatric Hospitals, and Critical Access Hospitals (CAHs), including Cancer 

Centers and Long-Term Care Hospitals (LTCHs)

• Emergency Medical Treatment & Labor Act (EMTALA). CMS is waiving the enforcement

of section 1867(a) of the Act. This will allow hospitals, psychiatric hospitals, and critical

access hospitals (CAHs) to screen patients at a location offsite from the hospital’s campus

to prevent the spread of COVID-19, so long as it is not inconsistent with a state’s emergency

preparedness or pandemic plan.

• Verbal Orders. CMS is waiving the requirements of 42 CFR §482.23, §482.24 and

§485.635(d)(3) to provide additional flexibility related to verbal orders where readback verification is required, but authentication may occur later than 48 hours. This will

allow more efficient treatment of patients in surge situations. Specifically, the following

requirements are waived:

• §482.23(c)(3)(i) - If verbal orders are used for the use of drugs and biologicals (except

immunizations), they are to be used infrequently.

• §482.24(c)(2) - All orders, including verbal orders, must be dated, timed, and

authenticated promptly by the ordering practitioner or by another practitioner who is

responsible for the care of the patient.

• §482.24(c)(3) - Hospitals may use pre-printed and electronic standing orders, order sets,

and protocols for patient orders. This would include all subparts at §482.24(c)(3).

• §485.635(d)(3) - Although the regulation requires that medication administration be

based on a written, signed order, this does not preclude the CAH from using verbal

orders. A practitioner responsible for the care of the patient must authenticate the order

in writing as soon as possible after the fact.
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• Reporting Requirements. CMS is waiving the requirements at 42 CFR §482.13(g) (1)(i)-(ii), 

which require that hospitals report patients in an intensive care unit whose death is caused 

by their disease, but who required soft wrist restraints to prevent pulling tubes/IVs, no later 

than the close of business on the next business day. Due to current hospital surge, CMS is 

waiving this requirement to ensure that hospitals are focusing on increased patient care 

demands and increased patient census, provided any death where the restraint may have 

contributed is still reported within standard time limits (i.e., close of business on the next 

business day following knowledge of the patient’s death). 

• Patient Rights. CMS is waiving requirements under 42 CFR §482.13 only for hospitals that 

are considered to be impacted by a widespread outbreak of COVID-19. Hospitals that are 

located in a state which has widespread confirmed cases (i.e., 51 or more confirmed cases*) 

as updated on the CDC website, CDC States Reporting Cases of COVID-19, at 

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html, would not 

be required to meet the following requirements: 

• §482.13(d)(2) - With respect to timeframes in providing a copy of a medical record.

• §482.13(h) - Related to patient visitation, including the requirement to have written 

policies and procedures on visitation of patients who are in COVID-19 isolation and 

quarantine processes. 

• §482.13(e)(1)(ii) - Regarding seclusion.

*The waiver flexibility is based on the number of confirmed cases as reported by CDC and 

will be assessed accordingly when COVID-19 confirmed cases decrease.

• Sterile Compounding. CMS is waiving requirements (also outlined in USP797) at 42 CFR 

§482.25(b)(1) and §485.635(a)(3) in order to allow used face masks to be removed and 

retained in the compounding area to be re-donned and reused during the same work shift 

in the compounding area only. This will conserve scarce face mask supplies. CMS will not 

review the use and storage of face masks under these requirements.

• Detailed Information Sharing for Discharge Planning for Hospitals and CAHs. CMS is 

waiving the requirement 42 CFR §482.43(a)(8), §482.61(e), and §485.642(a)(8) to provide 

detailed information regarding discharge planning, described below: 

• The hospital, psychiatric hospital, and CAH must assist patients, their families, or the 

patient’s representative in selecting a post-acute care provider by using and sharing data 

that includes, but is not limited to, home health agency (HHA), skilled nursing facility 

(SNF), inpatient rehabilitation facility (IRF), and long-term care hospital (LTCH) quality 

measures and resource use measures. The hospital must ensure that the post-acute care 

data on quality measures and resource use measures is relevant and applicable to the 

patient’s goals of care and treatment preferences.

• CMS is maintaining the discharge planning requirements that ensure a patient is 

discharged to an appropriate setting with the necessary medical information and goals 

of care as described in 42 CFR §482.43(a)(1)-(7) and (b).
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• Limiting Detailed Discharge Planning for Hospitals. CMS is waiving all the requirements

and subparts at 42 CFR §482.43(c) related to post-acute care services so as to expedite the

safe discharge and movement of patients among care settings, and to be responsive to

fluid situations in various areas of the country. CMS is maintaining the discharge planning

requirements that ensure a patient is discharged to an appropriate setting with the

necessary medical information and goals of care as described in 42 CFR §482.43(a)(1)-(7)

and (b). CMS is waiving the more detailed requirement that hospitals ensure those patients

discharged home and referred for HHA services, or transferred to a SNF for post-hospital

extended care services, or transferred to an IRF or LTCH for specialized hospital services,

must:

• §482.43(c)(1): Include in the discharge plan a list of HHAs, SNFs, IRFs, or LTCHs that are

available to the patient.

• §482.43(c)(2): Inform the patient or the patient’s representative of their freedom to

choose among participating Medicare providers and suppliers of post-discharge services.

• §482.43(c)(3): Identify in the discharge plan any HHA or SNF to which the patient is

referred in which the hospital has a disclosable financial interest, as specified by the

Secretary, and any HHA or SNF that has a disclosable financial interest in a hospital

under Medicare.

• Medical Staff. CMS is waiving requirements under 42 CFR §482.22(a)(1)-(4) to allow for

physicians whose privileges will expire to continue practicing at the hospital and for new

physicians to be able to practice before full medical staff/governing body review and

approval to address workforce concerns related to COVID-19. CMS is waiving §482.22(a)

(1)-(4) regarding details of the credentialing and privileging process. (Please also refer to

Practitioner Locations Blanket Waiver listed below.)

• Medical Records. CMS is waiving requirements under 42 CFR §482.24(a) through

(c), which cover the subjects of the organization and staffing of the medical records

department, requirements for the form and content of the medical record, and record

retention requirements, and these flexibilities may be implemented so long as they are

not inconsistent with a state’s emergency preparedness or pandemic plan. CMS is waiving

§482.24(c)(4)(viii) related to medical records to allow flexibility in completion of medical

records within 30 days following discharge from a hospital. This flexibility will allow clinicians

to focus on the patient care at the bedside during the pandemic.

• Flexibility in Patient Self Determination Act Requirements (Advance Directives). CMS

is waiving the requirements at sections 1902(a)(58) and 1902(w)(1)(A) of the Act (for

Medicaid); 1852(i) of the Act (for Medicare Advantage); and 1866(f) of the Act and 42 CFR

§489.102 (for Medicare), which require hospitals and CAHs to provide information about

their advance directive policies to patients. CMS is waiving this requirement to allow for staff 

to more efficiently deliver care to a larger number of patients.
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• Physical Environment. CMS is waiving certain requirements under the Medicare conditions 

of participation at 42 CFR §482.41 and §485.623 to allow for flexibilities during hospital, 

psychiatric hospital, and CAH surges. CMS will permit non-hospital buildings/space to be 

used for patient care and quarantine sites, provided that the location is approved by the 

state (ensuring that safety and comfort for patients and staff are sufficiently addressed) and 

so long as it is not inconsistent with a state’s emergency preparedness or pandemic plan. 

This allows for increased capacity and promotes appropriate cohorting of COVID-19 patients.

• Telemedicine. CMS is waiving the provisions related to telemedicine at 42 CFR §482.12(a)

(8)–(9) for hospitals and §485.616(c) for CAHs, making it easier for telemedicine services to 

be furnished to the hospital’s patients through an agreement with an off-site hospital. This 

allows for increased access to necessary care for hospital and CAH patients, including access 

to specialty care. 

• Physician Services. CMS is waiving requirements under 42 CFR §482.12(c)(1)–(2) and 

§482.12(c)(4), which requires that Medicare patients be under the care of a physician. 

This waiver may be implemented so long as it is not inconsistent with a state’s emergency 

preparedness or pandemic plan. This allows hospitals to use other practitioners to the 

fullest extent possible.

• Anesthesia Services. CMS is waiving requirements under 42 CFR §482.52(a)(5), §485.639(c)

(2), and §416.42 (b)(2) that a certified registered nurse anesthetist (CRNA) is under the 

supervision of a physician in paragraphs §482.52(a)(5) and §485.639(c)(2). CRNA supervision 

will be at the discretion of the hospital and state law. This waiver applies to hospitals, 

CAHs, and Ambulatory Surgical Centers (ASCs). These waivers will allow CRNAs to function 

to the fullest extent of their licensure, and may be implemented so long as they are not 

inconsistent with a state’s emergency preparedness or pandemic plan.

• Utilization Review. CMS is waiving certain requirements under 42 CFR §482.1(a)(3) and 42 

CFR §482.30 which address the statutory basis for hospitals and includes the requirement 

that hospitals participating in Medicare and Medicaid must have a utilization review plan 

that meets specified requirements. 

• CMS is waiving the entire utilization review condition of participation Utilization 

Review (UR) at §482.30, which requires that a hospital must have a UR plan with a UR 

committee that provides for a review of services furnished to Medicare and Medicaid 

beneficiaries to evaluate the medical necessity of the admission, duration of stay, 

and services provided. These flexibilities may be implemented so long as they are not 

inconsistent with a state’s emergency preparedness or pandemic plan. Removing these 

administrative requirements will allow hospitals to focus more resources on providing 

direct patient care. 
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• Written Policies and Procedures for Appraisal of Emergencies at Off Campus Hospital 

Departments. CMS is waiving 42 CFR §482.12(f)(3), emergency services, with respect 

to surge facilities only, such that written policies and procedures for staff to use when 

evaluating emergencies are not required for surge facilities. This removes the burden 

on facilities to develop and establish additional policies and procedures at their surge 

facilities or surge sites related to the assessment, initial treatment and referral of patients. 

These flexibilities may be implemented so long as they are not inconsistent with a state’s 

emergency preparedness or pandemic plan.

• Emergency Preparedness Policies and Procedures. CMS is waiving 42 CFR §482.15(b) and 

§485.625(b), which requires the hospital and CAH to develop and implement emergency 

preparedness policies and procedures, and §482.15(c)(1)–(5) and §485.625(c)(1)–(5) which 

requires that the emergency preparedness communication plans for hospitals and CAHs 

to contain specified elements with respect to the surge site. The requirement under the 

communication plan requires hospitals and CAHs to have specific contact information for 

staff, entities providing services under arrangement, patients’ physicians, other hospitals 

and CAHs, and volunteers. This would not be an expectation for the surge site. This waiver 

applies to both hospitals and CAHs, and removes the burden on facilities to establish these 

policies and procedures for their surge facilities or surge sites.

• Quality Assessment and Performance Improvement Program. CMS is waiving 42 CFR 

§482.21(a)–(d) and (f), and §485.641(a), (b), and (d), which provide details on the scope 

of the program, the incorporation, and setting priorities for the program’s performance 

improvement activities, and integrated Quality Assurance & Performance Improvement 

programs (for hospitals that are part of a hospital system). These flexibilities, which apply 

to both hospitals and CAHs, may be implemented so long as they are not inconsistent with 

a state’s emergency preparedness or pandemic plan. We expect any improvements to the 

plan to focus on the Public Health Emergency (PHE). While this waiver decreases burden 

associated with the development of a hospital or CAH QAPI program, the requirement 

that hospitals and CAHs maintain an effective, ongoing, hospital-wide, data-driven quality 

assessment and performance improvement program will remain. This waiver applies to both 

hospitals and CAHs.

• Nursing Services. CMS is waiving the requirements at 42 CFR §482.23(b)(4), which 

requires the nursing staff to develop and keep current a nursing care plan for each patient, 

and §482.23(b)(7), which requires the hospital to have policies and procedures in place 

establishing which outpatient departments are not required to have a registered nurse 

present. These waivers allow nurses increased time to meet the clinical care needs of each 

patient and allows for the provision of nursing care to an increased number of patients. 

In addition, we expect that hospitals will need relief for the provision of inpatient services 

and as a result, the requirement to establish nursing-related policies and procedures for 

outpatient departments is likely of lower priority. These flexibilities apply to both hospitals 

and CAHs §485.635(d)(4), and may be implemented so long as they are not inconsistent 

with a state’s emergency preparedness or pandemic plan. 
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• Food and Dietetic Services. CMS is waiving the requirement at paragraph 42 CFR §482.28(b)

(3), which requires providers to have a current therapeutic diet manual approved by

the dietitian and medical staff readily available to all medical, nursing, and food service

personnel. Such manuals would not need to be maintained at surge capacity sites. These

flexibilities may be implemented so long as they are not inconsistent with a state’s

emergency preparedness or pandemic plan. Removing these administrative requirements

will allow hospitals to focus more resources on providing direct patient care.

• Respiratory Care Services. CMS is waiving the requirements at 42 CFR §482.57(b)(1)

that require hospitals to designate in writing the personnel qualified to perform specific

respiratory care procedures and the amount of supervision required for personnel to carry

out specific procedures. These flexibilities may be implemented so long as they are not

inconsistent with a state’s emergency preparedness or pandemic plan. Not being required to

designate these professionals in writing will allow qualified professionals to operate to the

fullest extent of their licensure and training in providing patient care.

• CAH Personnel Qualifications. CMS is waiving the minimum personnel qualifications

for clinical nurse specialists at paragraph 42 CFR §485.604(a)(2), nurse practitioners at

paragraph §485.604(b)(1)–(3), and physician assistants at paragraph §485.604(c)(1)–(3).

Removing these Federal personnel requirements will allow CAHs to employ individuals in

these roles who meet state licensure requirements and provide maximum staffing flexibility.

These flexibilities should be implemented so long as they are not inconsistent with a state’s

emergency preparedness or pandemic plan.

• CAH Staff Licensure. CMS is deferring to staff licensure, certification, or registration to state

law by waiving 42 CFR §485.608(d) regarding the requirement that staff of the CAH be

licensed, certified, or registered in accordance with applicable federal, state, and local laws

and regulations. This waiver will provide maximum flexibility for CAHs to use all available

clinicians. These flexibilities may be implemented so long as they are not inconsistent with a

state’s emergency preparedness or pandemic plan.

• CAH Status and Location. CMS is waiving the requirement at 42 CFR §485.610(b) that the

CAH be located in a rural area or an area being treated as being rural, allowing the CAH

flexibility in the establishment of surge site locations. CMS is also waiving the requirement

at §485.610(e) regarding the CAH’s off-campus and co-location requirements, allowing

the CAH flexibility in establishing temporary off-site locations. In an effort to facilitate the

establishment of CAHs without walls, these waivers will suspend restrictions on CAHs

regarding their rural location and their location relative to other hospitals and CAHs.

These flexibilities may be implemented so long as they are not inconsistent with a state’s

emergency preparedness or pandemic plan.
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• CAH Length of Stay. CMS is waiving the requirements that CAHs limit the number of beds 

to 25, and that the length of stay be limited to 96 hours under the Medicare conditions of 

participation for number of beds and length of stay at 42 CFR §485.620. 

• Temporary Expansion Locations: For the duration of the PHE related to COVID-19, CMS 

is waiving certain requirements under the Medicare conditions of participation at 42 CFR 

§482.41 and §485.623 (as noted elsewhere in this waiver document) and the providerbased department requirements at §413.65 to allow hospitals to establish and operate as 

part of the hospital any location meeting those conditions of participation for hospitals that 

continue to apply during the PHE. This waiver also allows hospitals to change the status of 

their current provider-based department locations to the extent necessary to address the 

needs of hospital patients as part of the state or local pandemic plan. This extends to any 

entity operating as a hospital (whether a current hospital establishing a new location or 

an Ambulatory Surgical Center (ASC) enrolling as a hospital during the PHE pursuant to a 

streamlined enrollment and survey and certification process) so long as the relevant location 

meets the conditions of participation and other requirements not waived by CMS. This 

waiver will enable hospitals to meet the needs of Medicare beneficiaries. 

Housing Acute Care Patients in the IRF or Inpatient Psychiatric Facility (IPF) Excluded 

Distinct Part Units 

• CMS is waiving requirements to allow acute care hospitals to house acute care inpatients 

in excluded distinct part units, such as excluded distinct part unit IRFs or IPFs, where the 

distinct part unit’s beds are appropriate for acute care inpatients. The Inpatient Prospective 

Payment System (IPPS) hospital should bill for the care and annotate the patient’s medical 

record to indicate the patient is an acute care inpatient being housed in the excluded unit 

because of capacity issues related to the disaster or emergency. 

Care for Excluded Inpatient Psychiatric Unit Patients in the Acute Care Unit of a 

Hospital

• CMS is allowing acute care hospitals with excluded distinct part inpatient psychiatric units to 

relocate inpatients from the excluded distinct part psychiatric unit to an acute care bed and 

unit as a result of a disaster or emergency. The hospital should continue to bill for inpatient 

psychiatric services under the Inpatient Psychiatric Facility Prospective Payment System 

for these patients and annotate the medical record to indicate the patient is a psychiatric 

inpatient being cared for in an acute care bed because of capacity or other exigent 

circumstances related to the COVID-19 emergency. This waiver may be utilized where 

the hospital’s acute care beds are appropriate for psychiatric patients and the staff and 

environment are conducive to safe care. For psychiatric patients, this includes assessment 

of the acute care bed and unit location to ensure those patients at risk of harm to self and 

others are safely cared for.
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Care for Excluded Inpatient Rehabilitation Unit Patients in the Acute Care Unit of a 

Hospital 

• CMS is allowing acute care hospitals with excluded distinct part inpatient rehabilitation

units that, as a result of a disaster or emergency, need to relocate inpatients from the

excluded distinct part rehabilitation unit to an acute care bed and unit as a result of this

PHE. The hospital should continue to bill for inpatient rehabilitation services under the

inpatient rehabilitation facility prospective payment system for these patients and annotate

the medical record to indicate the patient is a rehabilitation inpatient being cared for in an

acute care bed because of capacity or other exigent circumstances related to the disaster or

emergency. This waiver may be utilized where the hospital’s acute care beds are appropriate

for providing care to rehabilitation patients and such patients continue to receive intensive

rehabilitation services.

Flexibility for Inpatient Rehabilitation Facilities Regarding the “60 Percent Rule” 

• CMS is allowing IRFs to exclude patients from the freestanding hospital’s or excluded

distinct part unit’s inpatient population for purposes of calculating the applicable thresholds

associated with the requirements to receive payment as an IRF (commonly referred to as

the “60 percent rule”) if an IRF admits a patient solely to respond to the emergency and

the patient’s medical record properly identifies the patient as such. In addition, during

the applicable waiver time period, we would also apply the exception to facilities not yet

classified as IRFs, but that are attempting to obtain classification as an IRF.

Extension for Inpatient Prospective Payment System (IPPS) Wage Index Occupational 

Mix Survey Submission

• CMS collects data every 3 years on the occupational mix of employees for each short-term,

acute care hospital participating in the Medicare program. Completed 2019 Occupational

Mix Surveys, Hospital Reporting Form CMS-10079, for the Wage Index Beginning FY 2022,

are due to the Medicare Administrative Contractors (MACs) on the Excel hospital reporting

form available at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/

AcuteInpatientPPS/Wage-Index-Files.html by July 1, 2020. CMS is currently granting an

extension for hospitals nationwide affected by COVID-19 until August 3, 2020. If hospitals

encounter difficulty meeting this extended deadline date, hospitals should communicate

their concerns to CMS via their MAC, and CMS may consider an additional extension if CMS

determines it is warranted.
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Supporting Care for Patients in Long-Term Care Acute Hospitals (LTCHs)

• Allows a LTCH to exclude patient stays where an LTCH admits or discharges patients in order

to meet the demands of the emergency from the 25-day average length of stay requirement,

which allows these facilities to be paid as LTCHs.

Care for Patients in Extended Neoplastic Disease Care Hospitals 

• CMS is allowing extended neoplastic disease care hospitals to exclude inpatient stays where

the hospital admits or discharges patients in order to meet the demands of the emergency

from the greater than 20-day average length of stay requirement, which allows these

facilities to be excluded from the hospital inpatient prospective payment system and paid

an adjusted payment for Medicare inpatient operating and capital-related costs under the

reasonable cost-based reimbursement rules as authorized under Section 1886(d)(1)(B)(vi) of

the Act and §42 CFR 412.22(i).

Long-Term Care Facilities and Skilled Nursing Facilities (SNFs) and/or 

Nursing Facilities (NFs)

• 3-Day Prior Hospitalization. Using the authority under Section 1812(f) of the Act, CMS is

waiving the requirement for a 3-day prior hospitalization for coverage of a SNF stay, which

provides temporary emergency coverage of SNF services without a qualifying hospital stay,

for those people who experience dislocations, or are otherwise affected by COVID-19. In

addition, for certain beneficiaries who recently exhausted their SNF benefits, it authorizes

renewed SNF coverage without first having to start a new benefit period (this waiver will

apply only for those beneficiaries who have been delayed or prevented by the emergency

itself from commencing or completing the process of ending their current benefit period

and renewing their SNF benefits that would have occurred under normal circumstances).

• Reporting Minimum Data Set. CMS is waiving 42 CFR 483.20 to provide relief to SNFs on the

timeframe requirements for Minimum Data Set assessments and transmission.

• Staffing Data Submission. CMS is waiving 42 CFR 483.70(q) to provide relief to long-term

care facilities on the requirements for submitting staffing data through the Payroll-Based

Journal system.

• Waive Pre-Admission Screening and Annual Resident Review (PASARR). CMS is waiving

42 CFR 483.20(k) allowing states and nursing homes to suspend these assessments for new

residents for 30 days. After 30 days, new patients admitted to nursing homes with a mental

illness (MI) or intellectual disability (ID) should receive the assessment as soon as resources

become available.
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• Physical Environment. CMS is waiving requirements related at 42 CFR 483.90, specifically

the following:

• Provided that the state has approved the location as one that sufficiently addresses

safety and comfort for patients and staff, CMS is waiving requirements under § 483.90

to allow for a non-SNF building to be temporarily certified and available for use by a

SNF in the event there are needs for isolation processes for COVID-19 positive residents,

which may not be feasible in the existing SNF structure to ensure care and services

during treatment for COVID-19 are available while protecting other vulnerable adults.

CMS believes this will also provide another measure that will free up inpatient care beds

at hospitals for the most acute patients while providing beds for those still in need of

care. CMS will waive certain conditions of participation and certification requirements

for opening a NF if the state determines there is a need to quickly stand up a temporary

COVID-19 isolation and treatment location.

• CMS is also waiving requirements under 42 CFR 483.90 to temporarily allow for

rooms in a long-term care facility not normally used as a resident’s room, to be used

to accommodate beds and residents for resident care in emergencies and situations

needed to help with surge capacity. Rooms that may be used for this purpose include

activity rooms, meeting/conference rooms, dining rooms, or other rooms, as long

as residents can be kept safe, comfortable, and other applicable requirements for

participation are met. This can be done so long as it is not inconsistent with a state’s

emergency preparedness or pandemic plan, or as directed by the local or state health

department.

• Resident Groups. CMS is waiving the requirements at 42 CFR 483.10(f)(5), which ensure

residents can participate in-person in resident groups. This waiver would only permit

the facility to restrict in-person meetings during the national emergency given the

recommendations of social distancing and limiting gatherings of more than ten people.

Refraining from in-person gatherings will help prevent the spread of COVID-19.

• Training and Certification of Nurse Aides. CMS is waiving the requirements at 42 CFR

483.35(d) (with the exception of 42 CFR 483.35(d)(1)(i)), which require that a SNF and

NF may not employ anyone for longer than four months unless they met the training

and certification requirements under § 483.35(d). CMS is waiving these requirements to

assist in potential staffing shortages seen with the COVID-19 pandemic. To ensure the

health and safety of nursing home residents, CMS is not waiving 42 CFR § 483.35(d)(1)(i),

which requires facilities to not use any individual working as a nurse aide for more than

four months, on a full-time basis, unless that individual is competent to provide nursing

and nursing related services. We further note that we are not waiving § 483.35(c), which

requires facilities to ensure that nurse aides are able to demonstrate competency in skills

and techniques necessary to care for residents’ needs, as identified through resident

assessments, and described in the plan of care.
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• Physician Visits in Skilled Nursing Facilities/Nursing Facilities. CMS is waiving the 

requirement in 42 CFR 483.30 for physicians and non-physician practitioners to perform inperson visits for nursing home residents and allow visits to be conducted, as appropriate, via 

telehealth options.

• Resident roommates and grouping. CMS is waiving the requirements in 42 CFR 483.10(e)

(5), (6), and (7) solely for the purposes of grouping or cohorting residents with respiratory 

illness symptoms and/or residents with a confirmed diagnosis of COVID-19, and separating 

them from residents who are asymptomatic or tested negative for COVID-19. This action 

waives a facility’s requirements, under 42 CFR 483.10, to provide for a resident to share a 

room with his or her roommate of choice in certain circumstances, to provide notice and 

rationale for changing a resident’s room, and to provide for a resident’s refusal a transfer to 

another room in the facility. This aligns with CDC guidance to preferably place residents in 

locations designed to care for COVID-19 residents, to prevent the transmission of COVID-19 

to other residents.

• Resident Transfer and Discharge. CMS is waiving requirements in 42 CFR 483.10(c)(5); 

483.15(c)(3), (c)(4)(ii), (c)(5)(i) and (iv), (c)(9), and (d); and § 483.21(a)(1)(i), (a)(2)(i), and (b)

(2)(i) (with some exceptions) to allow a long term care (LTC) facility to transfer or discharge 

residents to another LTC facility solely for the following cohorting purposes:

1. Transferring residents with symptoms of a respiratory infection or confirmed diagnosis 

of COVID-19 to another facility that agrees to accept each specific resident, and is 

dedicated to the care of such residents;

2. Transferring residents without symptoms of a respiratory infection or confirmed to not 

have COVID-19 to another facility that agrees to accept each specific resident, and is 

dedicated to the care of such residents to prevent them from acquiring COVID-19; or

3. Transferring residents without symptoms of a respiratory infection to another facility 

that agrees to accept each specific resident to observe for any signs or symptoms of a 

respiratory infection over 14 days.

Exceptions:

• These requirements are only waived in cases where the transferring facility receives 

confirmation that the receiving facility agrees to accept the resident to be transferred or 

discharged. Confirmation may be in writing or verbal. If verbal, the transferring facility 

needs to document the date, time and person that the receiving facility communicated 

agreement. 

• In § 483.10, we are only waiving the requirement, under § 483.10(c)(5), that a facility 

provide advance notification of options relating to the transfer or discharge to another 

facility. Otherwise, all requirements related to § 483.10 are not waived. Similarly, in § 

483.15, we are only waiving the requirement, under § 483.15(c)(3), (c)(4)(ii), (c)(5)(i) 

and (iv), and (d), for the written notice of transfer or discharge to be provided before the 

transfer or discharge. This notice must be provided as soon as practicable.
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• In § 483.21, we are only waiving the timeframes for certain care planning requirements 

for residents who are transferred or discharged for the purposes explained in 1–3 above. 

Receiving facilities should complete the required care plans as soon as practicable, 

and we expect receiving facilities to review and use the care plans for residents from 

the transferring facility, and adjust as necessary to protect the health and safety of the 

residents the apply to. 

• These requirements are also waived when the transferring residents to another facility, 

such as a COVID-19 isolation and treatment location, with the provision of services 

“under arrangements,” as long as it is not inconsistent with a state’s emergency 

preparedness or pandemic plan, or as directed by the local or state health department.

In these cases, the transferring LTC facility need not issue a formal discharge, as it is 

still considered the provider and should bill Medicare normally for each day of care. 

The transferring LTC facility is then responsible for reimbursing the other provider that 

accepted its resident(s) during the emergency period. 

• If the LTC facility does not intend to provide services under arrangement, the 

COVID-19 isolation and treatment facility is the responsible entity for Medicare 

billing purposes. The LTC facility should follow the procedures described in 40.3.4 of 

the Medicare Claims Processing Manual (https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/clm104c06.pdf) to submit a discharge bill 

to Medicare. The COVID-19 isolation and treatment facility should then bill Medicare 

appropriately for the type of care it is providing for the beneficiary. If the COVID-19 

isolation and treatment facility is not yet an enrolled provider, the facility should 

enroll through the provider enrollment hotline for the Medicare Administrative 

Contractor that services their geographic area to establish temporary Medicare 

billing privileges. 

We remind LTC facilities that they are responsible for ensuring that any transfers (either 

within a facility, or to another facility) are conducted in a safe and orderly manner, and that 

each resident’s health and safety is protected.

We also remind states that under 42 CFR 488.426(a)(1), in an emergency, the State has the 

authority to transfer Medicaid and Medicare residents to another facility.

Home Health Agencies (HHAs) 

• Requests for Anticipated Payment (RAPs). CMS is allowing Medicare Administrative 

Contractors (MACs) to extend the auto-cancellation date of Requests for Anticipated 

Payment (RAPs) during emergencies.

• Reporting. CMS is providing relief to HHAs on the timeframes related to OASIS Transmission 

through the following actions below:

• Extending the 5-day completion requirement for the comprehensive assessment to 30 

days.

• Waiving the 30-day OASIS submission requirement. Delayed submission is permitted 

during the PHE. 
13

• Initial Assessments. CMS is waiving the requirements at 42 CFR §484.55(a) to allow HHAs to

perform Medicare-covered initial assessments and determine patients’ homebound status

remotely or by record review. This will allow patients to be cared for in the best environment

for them while supporting infection control and reducing impact on acute care and longterm care facilities. This will allow for maximizing coverage by already scarce physician and

advanced practice clinicians and allow those clinicians to focus on caring for patients with

the greatest acuity.

• Waive onsite visits for HHA Aide Supervision. CMS is waiving the requirements at 42 CFR

§484.80(h), which require a nurse to conduct an onsite visit every two weeks. This would

include waiving the requirements for a nurse or other professional to conduct an onsite

visit every two weeks to evaluate if aides are providing care consistent with the care plan,

as this may not be physically possible for a period of time. This waiver is also temporarily

suspending the 2-week aide supervision by a registered nurse for home health agencies

requirement at §484.80(h)(1), but virtual supervision is encouraged during the period of the

waiver.

Hospice

• Waive Requirement for Hospices to Use Volunteers. CMS is waiving the requirement at 42

CFR §418.78(e) that hospices are required to use volunteers (including at least 5% of patient

care hours). It is anticipated that hospice volunteer availability and use will be reduced

related to COVID-19 surge and potential quarantine.

• Comprehensive Assessments. CMS is waiving certain requirements at 42 CFR §418.54

related to updating comprehensive assessments of patients. This waiver applies the

timeframes for updates to the comprehensive assessment found at §418.54(d). Hospices

must continue to complete the required assessments and updates, however, the timeframes

for updating the assessment may be extended from 15 to 21 days.

• Waive Non-Core Services. CMS is waiving the requirement for hospices to provide certain

non-core hospice services during the national emergency, including the requirements at 42

CFR §418.72 for physical therapy, occupational therapy, and speech-language pathology.

• Waived Onsite Visits for Hospice Aide Supervision. CMS is waiving the requirements at

42 CFR §418.76(h), which require a nurse to conduct an onsite supervisory visit every two

weeks. This would include waiving the requirements for a nurse or other professional to

conduct an onsite visit every two weeks to evaluate if aides are providing care consistent

with the care plan, as this may not be physically possible for a period of time.
14

End-Stage Renal Dialysis (ESRD) Facilities 

• Training Program and Periodic Audits. CMS is waiving the requirement at 42 CFR §494.40(a) 

related to the condition on Water & Dialysate Quality, specifically that on-time periodic 

audits for operators of the water/dialysate equipment are waived to allow for flexibilities. 

• Defer Equipment Maintenance & Fire Safety Inspections. CMS is waiving the requirement 

at 42 CFR §494.60(b) for on-time preventive maintenance of dialysis machines and ancillary 

dialysis equipment. Additionally, CMS is also waiving the requirements under §494.60(d) 

which requires ESRD facilities to conduct on-time fire inspections. These waivers are 

intended to ensure that dialysis facilities are able to focus on the operations related to the 

Public Health Emergency.

• Emergency Preparedness. CMS is waiving the requirements at 42 CFR §494.62(d)(1)(iv) 

which requires ESRD facilities to demonstrate as part of their Emergency Preparedness 

Training and Testing Program, that staff can demonstrate that, at a minimum, its patient care 

staff maintains current CPR certification. CMS is waiving the requirement for maintenance 

of CPR certification during the COVID-19 emergency due to the limited availability of CPR 

classes. 

• Ability to Delay Some Patient Assessments. CMS is not waiving subsections (a) or (c) of 

42 CFR §494.80, but is waiving the following requirements at 42 CFR §494.80(b) related to 

the frequency of assessments for patients admitted to the dialysis facility. CMS is waiving 

the “on-time” requirements for the initial and follow up comprehensive assessments within 

the specified timeframes as noted below. This waiver applies to assessments conducted by 

members of the interdisciplinary team, including: a registered nurse, a physician treating the 

patient for ESRD, a social worker, and a dietitian. These waivers are intended to ensure that 

dialysis facilities are able to focus on the operations related to the Public Health Emergency.

Specifically, CMS is waiving:

• §494.80(b)(1): An initial comprehensive assessment must be conducted on all new 

patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar 

days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis 

session. 

• §494.80(b)(2): A follow up comprehensive reassessment must occur within 3 months 

after the completion of the initial assessment to provide information to adjust the 

patient’s plan of care specified in §494.90.

• Time Period for Initiation of Care Planning and Monthly Physician Visits. CMS is modifying 

two requirements related to care planning, specifically:

• 42 CFR §494.90(b)(2): CMS is modifying the requirement that requires the dialysis facility 

to implement the initial plan of care within the latter of 30 calendar days after admission 

to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first 

outpatient dialysis session. This modification will also apply to the requirement for 

monthly or annual updates of the plan of care within 15 days of the completion of the 

additional patient assessments. 
15

• §494.90(b)(4): CMS is modifying the requirement that requires the ESRD dialysis facility

to ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical

nurse specialist, or physician’s assistant providing ESRD care at least monthly, and

periodically while the hemodialysis patient is receiving in-facility dialysis. CMS is waiving

the requirement for a monthly in-person visit if the patient is considered stable and also

recommends exercising telehealth flexibilities, e.g. phone calls, to ensure patient safety.

• Dialysis Home Visits to Assess Adaptation and Home Dialysis Machine Designation. CMS is

waiving the requirement at 42 CFR §494.100(c)(1)(i) which requires the periodic monitoring

of the patient’s home adaptation, including visits to the patient’s home by facility personnel.

For more information on existing flexibilities for in-center dialysis patients to receive their

dialysis treatments in the home, or long-term care facility, reference QSO-20-19-ESRD.

• Home Dialysis Machine Designation – Clarification. The ESRD Conditions for Coverage

(CFCs) do not explicitly require that each home dialysis patient have their own designated

home dialysis machine. The dialysis facility is required to follow FDA labeling and

manufacturer’s directions for use to ensure appropriate operation of the dialysis machine

and ancillary equipment. Dialysis machines must be properly cleaned and disinfected to

minimize the risk of infection based on the requirements at 42 CFR §494.30 Condition:

Infection Control if used to treat multiple patients.

• Special Purpose Renal Dialysis Facilities (SPRDF) Designation Expanded. CMS authorizes

the establishment of SPRDFs under 42 CFR §494.120 to address access to care issues due to

COVID-19 and the need to mitigate transmission among this vulnerable population. This will

not include the normal determination regarding lack of access to care at §494.120(b) as this

standard has been met during the period of the national emergency. Approval as a Special

Purpose Renal Dialysis Facility related to COVID-19 does not require Federal survey prior to

providing services.

• Dialysis Patient Care Technician (PCT) Certification. CMS is modifying the requirement at

42 CFR §494.140(e)(4) for dialysis PCTs that requires certification under a state certification

program or a national commercially available certification program within 18 months of

being hired as a dialysis PCT for newly employed patient care technicians. CMS is aware of

the challenges that PCTs are facing with the limited availability and closures of testing sites

during the time of this crisis. CMS will allow PCTs to continue working even if they have not

achieved certification within 18 months or have not met on time renewals.

• Transferability of Physician Credentialing. CMS is modifying the requirement at 42 CFR

§494.180(c)(1) which requires that all medical staff appointments and credentialing are

in accordance with state law, including attending physicians, physician assistants, nurse

practitioners, and clinical nurse specialists. These waivers will allow physicians that are

appropriately credentialed at a certified dialysis facility to function to the fullest extent

of their licensure to provide care at designated isolation locations without separate

credentialing at that facility, and may be implemented so long as they are not inconsistent

with a state’s emergency preparedness or pandemic plan.
16

• Expanding availability of ESRD to Nursing Home Residents. CMS is waiving the following 

requirements related to Nursing Home residents:

• Furnishing dialysis services on the main premises: ESRD requirements at 42 CFR 

§494.180(d) require dialysis facilities to provide services directly on its main premises 

or on other premises that are contiguous with the main premises. CMS is waiving this 

requirement to allow dialysis facilities to provide service to its patients in the nursing 

home or skilled nursing facility. CMS continues to require that services provided to 

these nursing home residents are under the direction of the same governing body and 

professional staff as the resident’s usual Medicare-certified dialysis facility. Further, 

in order to ensure that care is safe, effective and is provided by trained and qualified 

personnel, CMS requires that the dialysis facility staff: furnish all dialysis care and 

services, provide all equipment and supplies necessary, maintain equipment and 

supplies in the nursing home, and complete all equipment maintenance, cleaning 

and disinfection using appropriate infection control procedures and manufacturer’s 

instructions for use.

• Clarification for billing procedures. Typically, ESRD beneficiaries are transported from a 

SNF/NF to an ESRD facility to receive renal dialysis services. In an effort to keep patients 

in their SNF/NF and decrease their risk of being exposed to COVID-19, ESRD facilities may 

temporarily furnish renal dialysis services to ESRD beneficiaries in the SNF/NF instead of 

the offsite ESRD facility. The in-center dialysis center should bill Medicare using Condition 

Code 71 (Full care unit. Billing for a patient who received staff-assisted dialysis services in a 

hospital or renal dialysis facility). The in-center dialysis center should also apply condition 

code DR to claims if all the treatments billed on the claim meet this condition or modifier 

CR on the line level to identify individual treatments meeting this condition. The ESRD 

provider would need to have their trained personnel administer the treatment in the SNF/

NF. In addition, the provider must follow the CFCs. In particular, under the CFCs is the 

requirement that to use a dialysis machine, the FDA-approved labeling must be adhered to 

§ 494.100 and it must be maintained and operated in accordance with the manufacturer’s 

recommendations (§ 494.60) and follow infection control requirements at § 494.30.

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

• When DMEPOS is lost, destroyed, irreparably damaged, or otherwise rendered unusable, 

CMS is allowing DME Medicare Administrative Contractors (MACs) to have the flexibility to 

waive replacements requirements such that the face-to-face requirement, a new physician’s 

order, and new medical necessity documentation are not required. Suppliers must still 

include a narrative description on the claim explaining the reason why the equipment must 

be replaced and are reminded to maintain documentation indicating that the DMEPOS was 

lost, destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a 

result of the emergency.
17

Practitioner Locations 

CMS is temporarily waiving requirements that out-of-state practitioners be licensed in the state 

where they are providing services when they are licensed in another state. CMS will waive 

the physician or non-physician practitioner licensing requirements when the following four 

conditions are met: 1) must be enrolled as such in the Medicare program; 2) must possess 

a valid license to practice in the state which relates to his or her Medicare enrollment; 3) is 

furnishing services – whether in person or via telehealth – in a state in which the emergency 

is occurring in order to contribute to relief efforts in his or her professional capacity; and, 4) is 

not affirmatively excluded from practice in the state or any other state that is part of the 1135 

emergency area.

• In addition to the statutory limitations that apply to 1135-based licensure waivers, an 1135 

waiver, when granted by CMS, does not have the effect of waiving state or local licensure 

requirements or any requirement specified by the state or a local government as a condition 

for waiving its licensure requirements. Those requirements would continue to apply unless 

waived by the state. Therefore, in order for the physician or non-physician practitioner to 

avail him- or herself of the 1135 waiver under the conditions described above, the state also 

would have to waive its licensure requirements, either individually or categorically, for the 

type of practice for which the physician or non-physician practitioner is licensed in his or her 

home state.

Provider Enrollment

• Non-Waiver CMS Action: CMS has a toll-free hotline for physicians and non-physician 

practitioners and Part A certified providers and suppliers establishing isolation facilities to 

enroll and receive temporary Medicare billing privileges.

• Waive the following screening requirements:

• Application Fee - (to the extent applicable).

• Criminal background checks associated with fingerprint-based criminal background 

checks (FCBC) (to the extent applicable) - 42 CFR §424.518.

• Site visits (to the extent applicable) - 42 CFR §424.517.

• Postpone all revalidation actions.

• Allow licensed providers to render services outside of their state of enrollment.

• Expedite any pending or new applications from providers.

• Allow physicians and other practitioners to render telehealth services from their home 

without reporting their home address on their Medicare enrollment while continuing to bill 

from their currently enrolled location.

• Allow opted-out physicians and non-physician practitioners to terminate their opt-out status 

early and enroll in Medicare to provide care to more patients. 
18

Medicare Appeals in Fee for Service (FFS), Medicare Advantage (MA) and Part D

CMS is allowing Medicare Administrative Contractors (MACs) and Qualified Independent 

Contractors (QICs) in the FFS program pursuant to 42 CFR §405.942 and 42 CFR §405.962 

(including for MA and Part D plans), as well as the MA and Part D Independent Review Entities 

(IREs) under 42 CFR §422.562, 42 CFR §423.562, 42 CFR §422.582 and 42 CFR §423.582, to allow 

extensions to file an appeal. CMS is allowing MACs and QICs in the FFS program under 42 CFR 

§405.950 and 42 CFR §405.966 and the MA and Part D IREs to waive requests for timeliness

requirements for additional information to adjudicate appeals.

• CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.910 and MA and

Part D plans, as well as the MA and Part D IREs, to process an appeal even with incomplete

Appointment of Representation forms as outlined under 42 CFR §422.561 and 42 CFR

§423.560. However, any communications will only be sent to the beneficiary.

• CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.950 and 42 CFR

§405.966 (also including MA and Part D plans), as well as the MA and Part D IREs, to process

requests for appeals that do not meet the required elements using information that is

available as outlined within 42 CFR §422.561 and 42 CFR §423.560.

• CMS is allowing MACs and QICs in the FFS program under 42 CFR §405.950 and 42 CFR

§405.966 (also including MA and Part D plans), as well as the MA and Part D IREs under 42

CFR §422.562 and 42 CFR §423.562 to utilize all flexibilities available in the appeal process as

if good cause requirements are satisfied.

Medicaid and CHIP (as of 3/13/2020)

States and territories can request approval that certain statutes and implementing regulations 

be waived by CMS, pursuant to section 1135 of the Act. To assist states in this process, CMS 

released an 1135 Waiver Checklist to make it easier for states to receive federal waivers and 

implement flexibilities in their Medicaid and CHIP programs. States’ use of this 1135 checklist 

will expedite their ability to apply for and receive approval for 1135 waivers that are now 

available under the President’s national emergency declaration.

States and territories may submit a Section 1135 waiver request directly to their Center for 

Medicaid & CHIP Services (CMCS) state lead or Jackie Glaze, Acting Director, Medicaid & CHIP 

Operations Group, Center for Medicaid & CHIP Services at CMS by e-mail (Jackie.Glaze@cms.

hhs.gov) or letter. 

The following are examples of flexibilities that states and territories may seek through a Section 

1135 waiver request:

• Waive prior authorization requirements in fee-for-service programs.

• Permits providers located out of state/territory to provide care to another state’s Medicaid

enrollee impacted by the emergency.

• Temporarily suspend certain provider enrollment and revalidation requirements to increase

access to care.
19

• Temporarily waive requirements that physicians and other health care professionals be

licensed in the state in which they are providing services, so long as they have an equivalent

licensing in another state; and,

• Temporarily suspend requirements for certain pre-admission and annual screenings for

nursing home residents.

States and territories are encouraged to assess their needs and request these available 

flexibilities, which are more completely outlined in the Medicaid and CHIP Disaster Response 

Toolkit. For more information and to access the toolkit and the 1135 waiver checklist, visit: 

https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/index.html.

03/30/2020
20

ATTACHMENT A

Blanket Waivers of Sanctions under the Physician SelfReferral Law (also known as the “Stark Law”)

CMS has issued blanket waivers of sanctions under section 1877(g) of the Act. The blanket 

waivers may be used now without notifying CMS. Individual waivers of sanctions under 

section 1877(g) of the Act may be granted upon request. For more information, visit: 

https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Spotlight.

For resources and additional information on 1135 Waivers, please also visit:

• https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/CurrentEmergencies/Current-Emergencies-page

• https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/

SurveyCertEmergPrep/1135-Waivers

For questions please email: 1135waiver@cms.hhs.gov
21

Blanket Waivers: Stafford Act, Public Health Emergency 

(PHE) and Section 1135 Waivers

Background

On March 13, 2020, the President issued an emergency declaration under the Robert T. Stafford 

Disaster Relief and Emergency Assistance Act, 42 U.S.C. 5121-5207 (the “Stafford Act”) to 

declare a national health emergency. The Secretary of the Department of Health and Human 

Services (the Secretary) is authorized to waive certain Medicare, Medicaid and Children’s Health 

Insurance Program (CHIP) program requirements and conditions of participation under Section 

1135 of the Social Security Act once the President has declared an emergency through the 

Stafford Act1 and the Secretary has declared a Public Health Emergency (PHE). The Secretary 

issued a PHE on January 31, 20202

. As a result of this authority, CMS can grant waivers that will 

ease certain requirements for affected providers as stated under Section 1135 of the Social 

Security Act3

.

CMS can issue two types of waivers: blanket waivers and provider/supplier requested waivers. 

Specifics about the two types of waivers are outlined in detail below. Examples of these 1135 

waivers or modifications include:

• Conditions of participation or other certification requirements

• Program participation and similar requirements

• Preapproval requirements

• Requirements that physicians and other health care professionals be licensed in the State in

which they are providing services, so long as they have equivalent licensing in another State

(this waiver is for purposes of Medicare, Medicaid, and CHIP reimbursement only – state

law governs whether a non-Federal provider is authorized to provide services in the state

without state licensure)

• Emergency Medical Treatment and Labor Act (EMTALA)

• Sanctions under the physician self-referral law (also known as the “Stark Law”)

• Performance deadlines and timetables may be adjusted (but not waived)

• Limitations on payment for health care items and services furnished to Medicare Advantage

enrollees by non-network providers

Waivers under Section 1135 of the Social Security Act typically end no later than the termination 

of the emergency period, or 60 days from the date the waiver or modification is first published. 

The Secretary can extend the waiver by notice for additional periods of up to 60 days, up to the 

end of the emergency period.

1

 https://www.whitehouse.gov/wp-content/uploads/2020/03/LetterFromThePresident.pdf

2

 https://www.phe.gov/emergency/news/healthactions/phe/Pages/2019-nCoV.aspx

3

 https://www.phe.gov/emergency/news/healthactions/section1135/Pages/covid19-13March20.aspx
22

The 1135 waiver authority applies only to Federal requirements and does not apply to State 

requirements for licensure or conditions of participation.

In addition to the 1135 waiver authority, Section 1812(f) of the Social Security Act (the Act) 

authorizes the Secretary to provide for Skilled Nursing Facilities (SNF) coverage in the absence 

of a qualifying hospital stay, as long as this action does not increase overall program payments 

and does not alter the SNF benefit’s “acute care nature” (that is, its orientation toward relatively 

short-term and intensive care).

Federally certified/approved providers must continue to operate under normal rules and 

regulations, unless they have sought and have been granted modifications under the waiver 

authority from specific requirements.

In addition, the Coronavirus Preparedness and Response Supplemental Appropriations Act, as 

signed into law by the President on March 6, 2020, includes a provision allowing the Secretary 

to waive certain Medicare telehealth payment requirements during the PHE the Secretary 

declared on January 31, 2020 to allow beneficiaries in all areas of the country to receive 

telehealth services, including at their home. Under the waiver, limitations on where Medicare 

patients are eligible for telehealth will be removed during the emergency. In particular, patients 

outside of rural areas, and patients in their homes will be eligible for telehealth services, 

effective for services starting March 6, 20204

.

4

 https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf
23

CMS Section 1135 Waiver Authority: Blanket Waivers, 

Provider/Supplier Individual Waivers, Medicaid and 

Special Waivers

Medicare Blanket Waivers

• Approval: CMS implements specific waivers or modifications under the 1135 authority on

a “blanket” basis when a determination has been made that all similarly situated providers

in the emergency area need such a waiver or modification. These waivers prevent gaps in

access to care for beneficiaries impacted by the emergency. Once approved these waivers

apply automatically to all applicable providers and suppliers. Providers and suppliers do

not need to apply for an individual waiver if a blanket waiver is issued by CMS.

• Claims Submission for Blanket Waivers: When submitting claims covered by the blanket

waivers, the “DR” (disaster-related) condition code should be used for institutional billing

(i.e., claims submitted using the ASC X12 837 institutional claims format or paper Form

CMS-1450). The “CR” (catastrophe/disaster-related) modifier should be used for Part B

billing, both institutional and non-institutional (i.e., claims submitted using the ASC X12

837 professional claim format or paper Form CMS-1500 or, for pharmacies, in the NCPDP

format). This requirement does not apply for purposes of compliance with waivers (blanket

or individual) of sanctions under the physician self- referral law.

Medicare Provider/Supplier Individual Waivers

• Approval: Providers and suppliers can submit requests for individual 1135 waivers.

These requests must include a justification for the waiver and expected duration of the

modification requested. The State Survey Agency and CMS Survey Operations Group will

review the provider’s request and make appropriate decisions, usually on a case- by- case

basis. Providers and suppliers should keep careful records of beneficiaries to whom they

provide services, in order to ensure that proper payment may be made. Providers are

expected to come into compliance with any waived requirements prior to the end of the

emergency period.

• With the exception of physician self-referral law waivers, the process for requesting

an 1135 waiver is managed through the Survey Operations Group, and CMS locations,

previously known as the CMS Regional Offices. More information on the process is

located at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/

SurveyCertEmergPrep/1135-Waivers. The website includes contact information for each

CMS location. Facilities should ensure to review the process and identify the appropriate

contact based on the location of the facility.
24

Examples of Individual Requests for 1135 Waivers 

An individual hospital may request a waiver of COPs related to doubling of single occupancy 

patient rooms or a waiver of the requirement to discharge to a specified location or situation.

Waiver Request Process

You do not have to make a request for a blanket waiver that has already been issued, and 

you do not have to notify CMS if you are taking action in accordance with a waiver during the 

time period in which the waiver is valid. If you are requesting an 1135 waiver outside of those 

outlined in this document or are already available at the CMS Current Emergencies page, please 

send your request or questions about a request to 1135waiver@cms.hhs.gov.

Medicaid Waivers

Approval

CMS works with the states and territories to respond to public health emergencies and 

disasters. States and territories have multiple strategies available to support Medicaid and 

CHIP Operations and enrollees in times of crisis. Some of these strategies are available without 

needing approval from CMS while some disaster-related and Public Health Emergency legal 

authorities include:

• Medicaid State Plan Amendments;

• CHIP Disaster Relief State Plan Amendments;

• Verification Plans;

• 1915(c) Waivers Appendix K;

• 1135 Waivers; and

• 1115 Demonstrations.

In Medicaid and CHIP, 1135 waivers can be used to implement a range of flexibilities. Some 

of these include: provider enrollment and participation; Medicaid prior authorization 

requirements; pre-admission screening and annual resident review (PASRR) Level I and Level II 

Assessments for 30 days; extend minimum data set authorizations for nursing facility and SNF 

residents; state fair hearing and appeal process timelines; and reporting and oversight. Under 

1135 waivers, states also have flexibility on public notice, tribal consultation, and the effective 

dates of state plan amendment (SPA) submissions. For public notice, Section 1135 authority can 

be used to provide flexibility related to the need and timing for public notice associated with 

cost sharing, Alternative Benefit Plan (ABP) benefit and payment SPAs. Section 1135 authority 

can be used to provide flexibility related to the timing of tribal consultation including shortening 

consultation or conducting tribal consultation after submission of the SPA. For SPA submission 

dates, Section 1135 authority can be utilized to effectively permit states to submit a Medicaid 

SPA after the end of this quarter and still have an effective date retroactive to the date of the 

declaration by the Secretary of a Public Health Emergency.
25

In the event of a disaster or public health emergency, state Medicaid agencies should contact 

CMS for questions and waiver requests. More information on this process is located at: 

https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/index.html

Special Waivers

EMTALA:

Only two aspects of the EMTALA requirements can be waived under 1135 Waiver Authority: 1) 

Transfer of an individual who has not been stabilized, if the transfer arises out of an emergency 

or, 2) Redirection to another location (offsite alternate screening location) to receive a medical 

screening exam under a state emergency preparedness or pandemic plan. A waiver of EMTALA 

sanctions is effective only if actions under the waiver do not discriminate as to source of 

payment or ability to pay. Hospitals are generally able to manage the separation and flow of 

potentially infectious patients through alternate screening locations on the hospital campus.

Therefore, waivers to provide Medical Screening Examinations at an offsite alternate screening 

location not owned or operated by the hospital will be reviewed on a case by case basis. Please 

note, there is no waiver authority available for any other EMTALA requirement.

For the duration of the COVID-19 national emergency, CMS is waiving the enforcement of 

section 1867(a) of the Social Security Act (the Emergency Medical Treatment and Active Labor 

Act, or EMTALA). This will allow hospitals, psychiatric hospitals, and CAHs to screen patients at 

a location offsite from the hospital’s campus to prevent the spread of COVID-19, in accordance 

with the state emergency preparedness or pandemic plan.

Individual Physician Self-Referral Law Waiver Requests:

CMS has issued blanket waivers of sanctions under the physician self-referral law. The blanket 

waivers may be used now without notifying CMS. For more information, visit: https://www.

cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/Spotlight. 

Unlike other 1135 waiver requests, any requests for individual waivers of sanctions under the 

physician self- referral law related to COVID-19 will be handled by CMS Baltimore. Please send 

your request to 1877CallCenter@cms.hhs.gov and include the words “Request for 1877(g) 

Waiver” in the subject line of the email. All requests should include the following minimum 

information:

• Name and address of requesting entity;

• Name, phone number and email address of person designated to represent the entity;

• CMS Certification Number (CCN) or Taxpayer Identification Number (TIN);

• Nature of request.

Individual waivers may be granted only upon request and on a case-by-case basis and require 

specific details concerning the actual or proposed financial relationship between the referring 

physician(s) and the referred-to entity. Unless and until a waiver of sanctions under the 

physician self-referral law (i.e., a waiver of section 1877(g) of the Social Security Act) is granted 

to the requesting party(ies), such party(ies) must comply with section 1877 of the Social 

Security Act and the regulations at 42 CFR §411.350 et seq.
26

Helpful Website Resources

• Approved 1135 Waivers: https://www.cms.gov/files/document/covid19-emergencydeclaration-health-care-providers-fact-sheet.pdf

• Approved Telehealth Waivers: https://www.cms.gov/newsroom/fact-sheets/medicaretelemedicine-health-care-provider-fact-sheet

• 1135 Waiver Request Information: https://www.cms.gov/Medicare/Provider-Enrollmentand-Certification/SurveyCertEmergPrep/1135-Waivers

• Medicare Fee-For-Service Additional Emergency and Disaster-Related Policies and

Procedures That May Be Implemented Only With an §1135 Waiver: https://www.

cms.gov/About-CMS/Agency-Information/Emergency/Downloads/MedicareFFSEmergencyQsAs1135Waiver.pdf

• Blanket Waivers – Claims Submission: https://www.cms.gov/files/document/se20011.pdf

• Frequently Asked Questions – 1135 Waivers: https://www.cms.gov/About-CMS/AgencyInformation/Emergency/Downloads/MedicareFFS-EmergencyQsAs1135Waiver.pdf

• Frequently Asked Questions – non-1135 Waivers: https://www.cms.gov/About-CMS/

Agency-Information/Emergency/Downloads/Consolidated_Medicare_FFS_Emergency_

QsAs.pdf

• Medicaid Disaster Response Toolkit: https://www.medicaid.gov/state-resource-center/

disaster-response-toolkit/index.html

CMS Oversight

CMS remains committed to ensuring continuity of oversight activities during a national public 

health emergency. We continue to work State Survey Agencies and accrediting organizations, 

charged with inspecting Medicare and Medicaid providers to ensure compliance with Federal 

requirements, to ensure these activities are prioritized to allow providers to focus on current 

health and safety threats and provide needed care to beneficiaries. We will continue to monitor 

program operations to support proper enrollment and accurate billing practices. CMS will 

coordinate our oversight activities with the OIG and GAO.

03/30/2020