CMS Expands Ability of Hospitals to Provide Long-Term Care Services to COVID-19 Patients

Florida Gov. Ron DeSantis called on the leader of the Centers for Medicare & Medicaid Services (CMS) to establish flexibilities for caring for long-term care residents with COVID-19 — by letting skilled nursing facilities send them to the hospital.

While acknowledging that such individuals might not meet normal hospital admission criteria, DeSantis argued in a May 3 letter to CMS administrator Seema Verma that the inpatient setting could ensure better care if a given hospital “has vacant beds and sufficient surge capacity.”

The goal is to help stop the spread of the virus, which has ravaged SNFs and long-term care facilities across the U.S.


DeSantis called on Verma and CMS to find a way to appropriately reimburse hospitals that take in SNF patients who do not normally meet the criteria for admission to the acute setting.

“The inpatient setting should also be an option to extend the stay for COVID-19 positive patients admitted at a hospital that may otherwise be ready for discharge,” DeSantis wrote. “Returning a hospitalized COVID-19-positive patient to a nursing home that is ill-equipped to isolate and care for the patient can spark an outbreak in the nursing home.”

On May 11, the agency updated a recently issued set of waivers designed to provide flexibilities for health care providers to address COVID-19 to include a waiver to allow hospitals to establish SNF swing beds under the SNF prospective payment system (PPS).


To qualify, hospitals have to:

  • Not use SNF swing beds for acute care
  • Comply with all other hospital conditions of participation and other SNF provisions to the extent they are not waived
  • Be consistent with the state’s emergency preparedness or pandemic plan

The hospitals need to call the CMS Medicare Administrative Contractor (MAC) enrollment hotline to add swing bed services; they also have to attest that they “made a good faith effort” to exhaust other options, and that they will discharge the patients as soon as they can reasonably do so, whether to a SNF or at the end of the COVID-19 public health emergency.

The challenges of cohorting COVID-19 patients in the SNF setting has been made even worse by the lack of testing and the realities of asymptomatic transmission of the virus, which makes it almost impossible to know which patients need to be isolated.

CMS has issued a slew of waivers designed to make it easer for SNFs to transfer patients between care sites to allow for easier cohorting, or even the setup of COVID-19 facilities; the agency mandated that SNFs develop dedicated buildings or wings for COVID-19 SNF patients in early April.

DeSantis pointed to those waivers in his letter, recommending that CMS expand the March 28 flexibilities for long-term care facilities.

But all of those efforts have been focused on isolating COVID-19 patients in the SNF setting, and have not focused on the possibility of putting patients in the hospital. In fact, New York up until recently required that SNFs take in patients from the hospital without requiring a COVID-19 negative test; the Empire State changed that requirement on Sunday.

“In those situations where the long-term care facility does not intend to provide services under an arrangement with the hospital, and the hospital is assuming full responsibility for the patient’s care, CMS should allow the hospital to bill Medicare for a lower acuity hospital stay or establish a rate, such as the inpatient rehabilitation facility rate, that may be used in this instances,” DeSantis wrote.

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