Risk Adjustment

Coronavirus Updates

Updated regularly.


As the pandemic continues to affect risk adjustment programs, Episource helps you keep track of the government’s policy response.

The U.S. government is enacting policy and payers are reacting in real time to the novel coronavirus pandemic. To stay ahead of the curve on the latest risk-adjustment and related policy decisions, we created a regularly updated feed.

What You Need To Know:


  • Cases pass 4.4 million in US, 17 million total worldwide
  • $100 Billion approved in the Coronavirus Aid, Relief, and Economic Security (CARES) Act, 3/27/2020
  • CMS & The White House Release Recommendations to Re-Open Health Care Systems in Areas With low Incidence of COVID-19, 4/19/2020
  • World Passes Grim Milestone: 250,000 dead, 5/4/2020
  • America exceeds 80,000 COVID-19 dead in two months, 5/12/2020
  • 100,000 Americans dead from COVID-19, 5/27/2020
  • 120,000 Americans dead from COVID-19, 6/22/2020
  • Global Deaths pass 500,000, 6/28/2020
  • America registers over 60,000 new cases in new-single day record, 7/8/20
  • 150,000 Americans have now passed since the beginning of the pandemic, 7/29/2020

Thursday, 7/30/2020: CMS refuses to extend submissions deadline; still first week of September

On Friday, July 17, 2020, the Centers for Medicare & Medicaid Services (CMS) released a memo notifying Medicare Advantage Organizations, PACE Organizations, Medicare-Medicaid Plans and other contractors of the upcoming deadline to submit risk adjustment data for Payment Year (PY) 2021. Despite speculation that the Department of Health and Human Services (HHS) might delay the collection of data for use in calculating risk scores for PY 2021, CMS confirmed that the deadline, Friday, September 4th 2020, remains unchanged. For more information, visit https://www.cms.gov/.



Thursday, 6/11/2020: Trump Administration releases “New recommendations” to encourage health systems & facilities to reopen as COVID-19 cases decline.

On Wednesday, June 10, 2020, the Trump Administration and the Centers for Medicare & Medicaid Services (CMS) released recommendations for the re-opening of “facilities to provide Non-emergent Non-COVID-19 Healthcare.” The recommendations focus on the optimization of Telehealth services, continued shelter-in-place support for individuals at a higher risk of severe COVID-19 illness, how to offer care that cannot be provided virtually, and the kinds of precautions needed for facilities, workforce, and testing. Reopening is currently a fiercely contested topic across the United States as business and healthcare leaders have clashed over when reopening should occur and what steps are necessary to reach that point. Though the recommendations only apply to areas currently in Phase II (States and regions with no evidence of a rebound that satisfy the gathering criteria), considering the United States is recording over 1,000 COVID-19 deaths/ day, the timing of the release will be scrutinized. 



Tuesday, 5/26/2020: Trump Administration Changes Medicare Advantage Part D to Increase Coverage and Access
On Friday, May 22, 2020, The Centers for Medicare and Medicaid Services (CMS) released finalized requirements to increase access to Telehealth for seniors in Medicare Advantage (MA) plans. The changes expand supplemental benefits available for MA plan beneficiaries with chronic diseases and add additional support for beneficiaries in rural communities. Due to the ongoing COVID-19 public health crisis and quickly approaching MA & Part D bid deadline, CMS believes this approach will provide the most time and support for beneficiaries and their plans. For more information regarding the changes, CMS has released an updated Fact Sheet for 2021, and the Final Rule can be found and downloaded from the Federal Register.



Wednesday, 5/13/2020: CMS Issues Fiscal Year 2021 Inpatient Prospective Payment Systems (IPPS) for Acute Care Hospitals and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) Proposed Rule
On Monday, May 11th 2020, The Centers for Medicare & Medicaid Services (CMS) proposed policy changes on the Federal Register relating to Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals, the Long Term Care Hospital Prospective Payment System, and Fiscal Year 2021 Rates. The released rules:

-Increase payments for inpatient services by about 1.6 percent, or $2.07 billion, in fiscal year 2021.
-Decrease Disproportionate Share Hospital (DSH) payments by more than $500m in fiscal year 20201.
-Double down on price transparency, requiring payer-specific negotiated rates for inpatient services.

These proposed rule changes also include a new DRG, Add-on payments, Graduate medical education policy updates, inpatient quality reporting program reporting requirements, and more. For more information on the proposed rule changes, the proposed rule is available on the Federal Register, CMS’ Press Release is available, and so is a brief Fact Sheet explaining the details further. The deadline for submitting comments on the proposed rule is no later than 5 p.m. Eastern Daylight Time on July 10, 2020.



Friday, 5/8/2020: CMS & HHS Release Interim Final Rule With Comment Period to Give Medicare, Medicaid, Basic Health Program, and Exchange Services Providers Greater Flexibilities
On Friday, May 8th 2020, The Centers for Medicare & Medicaid Services (CMS), in conjunction with The Department of Health & Human Services, released an interim final rule with comment period (IFC) to give Medicare, Medicaid, Basic Health Program, and Exchange services providers the flexibilities needed to effectively respond to the COVID-19 public health crisis. The expansion covers nearly every kind of provider and supplier, greatly reduces regulations regarding “innovative uses of technology and capacity,” and retroactively covers services that date back to as early as January 27th, 2020. The further expansion of flexibilities, and back-dating of services will be useful for providers that need to offset inflating costs, but considering the scope and timeline of the virus, could cause reimbursement issues for healthcare providers. Comments on the expansion are currently open but, “to be assured consideration, comments must be received… no later than 5 p.m. on July 7, 2020.” Comments can be sent electronically to http://www.regulations.gov. For more information, see the official announcement on the Federal Register.



Monday, 5/4/2020: ONC Publishes Final Rules on Interoperability, Information Blocking and More; Delays Enforcement Until Future
On Friday, 5/1/2020, The Office of The National Coordinator for Health information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) published their final rules for interoperability, information blocking, health IT, and patient access in the Federal Register. As the country grapples with the public health crisis brought about by the global COVID-19 outbreak, The Department of Health & Human Services (HHS) has decided that the release of these rules would mark the start of implementation timetables but would delay enforcement until the future. However, HHS did release their proposed approach to carrying out the new information blocking rules and their associated penalties, allowing The HHS Office of Inspector General (OIG) to impose fines of up to $1 million per violation. For more information, view the official report on the Federal Register.



Friday, 5/1/2020: Trump Administration & CMS Issue Second Round of Expansive Regulatory Waivers and Rule Changes
The Trump Administration and the Centers for Medicare & Medicaid Services (CMS) just issued a second set of wide-reaching regulatory waivers and rule changes designed to expand access and care as America copes with a historic health crisis. The announced changes increase COVID-19 testing for Medicare & Medicaid beneficiaries, expands access to Telehealth services, and provides flexibilities for state and local governments to gradually reopen America.

“CMS’s goals during the pandemic are to 1) expand the healthcare workforce by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community or other states; 2) ensure that local hospitals and health systems have the capacity to handle COVID-19 patients through temporary expansion sites (also known as the CMS Hospital Without Walls initiative); 3) increase access to telehealth for Medicare patients so they can get care from their physicians and other clinicians while staying safely at home; 4) expand at-home and community-based testing to minimize transmission of COVID-19 among Medicare and Medicaid beneficiaries; and 5) put patients over paperwork by giving providers, healthcare facilities, Medicare Advantage and Part D plans, and states temporary relief from many reporting and audit requirements so they can focus on patient care.”

For background information on the rule changes & waivers, view the CMS Factsheet. For more information on the COVID-19 specific guidance, visit the CMS Coronavirus Waivers & Flexibilities page.



Wednesday, 4/29/2020: New Survey Shows Devastating Effect of COVID-19 on Continued ACO Participation
NAACOS, the National Association of ACOs, requested every Medicare Shared Savings Program (MSSP) and Next Generation ACO Model participants complete an online survey focused on the effects of COVID-19 on ACOs, early in April. The results were recently collected and paint a troubling picture for ACOs during the public health crisis: “almost 60 percent of respondents in risk-based models reporting they are likely to quit the ACO program to avoid financial losses stemming from the pandemic, and 77 percent of ACOs reporting they are “very concerned” about the impact of COVID-19 on their ACO’s 2020 performance.” Conisidering the deadline for track 2 and 3 ACOS to back out of program is coming up soon (May 31), we are continuing these concerning developments. For more information and to view the full survey report, visit NAACOS.



Monday, 4/27/2020: CMS Suspends Advance Payment Program, Reevaluates Accelerated Payment Program
Following a successful disbursement of more than $100 billion to healthcare providers and suppliers through the Advance Payment Program and Accelerated Payment Program, the Centers for Medicare & Medicaid Services (CMS) announced their plan to immediately suspend the Advance Payment Program to Part B suppliers and reevaluate the payment amounts allotted under the Accelerated Payment Program. Posted on Sunday, 4/26/2020, the press release makes clear that this does not mark the end of economic relief for healthcare providers and suppliers during the COVID-19 public health crisis. “Significant additional funding will continue to be available to hospitals and other healthcare providers through other programs,” such as the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act. For more information, see the updated Accelerated and Advance Payment Programs fact sheet.



Friday, 4/24/2020: CMS Details New Flexibilities for Health Care Organizations, Independent Freestanding Emergency Departments (IFEDs)
On 4/21/2020, the The Centers for Medicare and Medicaid Services (CMS) released a number of statements detailing the various flexibilities health care organizations can take while addressing the COVID-19 health emergency. The first guidance allows IFEDs to provide care to Medicare and Medicaid beneficiaries in four states to address possible surges in patients and increase capacity at care facilities. The second statement released was a detailed FAQ for individual and small plan guidance explaining the flexibilities they can utilize to mitigate COVID-19’s impact on providers. The third document CMS released on Tuesday was a replacement for rules issued 3/10/2020 relating to flexibilities Medicare Advantage Organizations (MAOs) and Part D sponsors may implement during the coronavirus disease 2019. “Due to the public health emergency posed by COVID-19 and the urgent need to ensure access to health care items and services covered by MA, Part D and Medicare-Medicaid plans, particularly in light of isolation and social distancing measures that are necessary to contain the spread of COVID-19, CMS is exercising its enforcement discretion to adopt a temporary policy of relaxed enforcement in connection with the policies discussed in this memo under the conditions outlined herein.” For more information, visit https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Current-Emergencies/Current-Emergencies-page



Wednesday, 4/22/2020: HHS Delays Enforcing CMS/ONC Interoperability Rules
On 4/21/2020, the Department of Health and Human Services released a statement that effectively delayed implementation of the department’s own interoperability rules, issued 3/9/2020. The original ruling paved the way for greater patient access to, and control of, information relating to personal health, but would require wide restructuring by public and private entities to meet the ambitious interoperability goals. However, considering the ongoing COVID-19 health emergency, the department has chosen to suspend enforcement of those rules and allow health-care organizations to prioritize the outbreak.

“ONC remains committed to ensuring that patients and providers can access electronic health information, when and where it matters most. During this critical time, we understand that resources need to be focused on fighting the COVID-19 pandemic. To support that important work and the information sharing efforts we are already seeing, ONC intends to exercise enforcement discretion for 3 months at the end of certain ONC Health IT Certification Program compliance dates associated with the ONC Cures Act Final Rule to provide flexibility while ensuring the goals of the rule remain on track.” – Don Rucker, MD, National Coordinator for Health Information Technology.

For more information on the announcements, visit https://www.cms.gov/Regulations-and-Guidance/Guidance/Interoperability/index to find the CMS announcement. Visit https://healthit.gov/curesrule to find the ONC announcement. And visit https://oig.hhs.gov/reports-and-publications/federal-register-notices/index.asp to find the OIG announcement.



Monday, 4/20/2020: CMS, White House Release Recommendations to Reopen America.
On 4/19/2020, the The Centers for Medicare and Medicaid Services (CMS), in tandem with The Office of The President of The United States, released new “recommendations to re-open health care systems in areas with low incidence of Covid-19”.
“The new recommendations are specifically targeted to communities that are in Phase 1 of the Guidelines for Opening Up America Again with low incidence or relatively low and stable incidence of COVID-19 cases. The recommendations update earlier guidance provided by CMS on limiting non-essential surgeries and medical procedures. The new CMS guidelines recommend a gradual transition and encourage health care providers to coordinate with local and state public health officials, and to review the availability of personal protective equipment (PPE) and other supplies, workforce availability, facility readiness, and testing capacity when making the decision to re-start or increase in-person care.” For more information, see CMS’ Recommendations for Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I



Friday, 4/17/2020: CMS to Increase Payments to Inpatient Prospective Payment System (IPPS) hospitals and Long-Term Care Hospitals, Medicare Payments for High Production Lab Tests.
As the government takes broad steps to mitigate the impact of the COVID-19 outbreak, The Centers for Medicare and Medicaid Services (CMS) have been taking more targeted approaches to the crisis, including “aggressive actions and exercising regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” These emergency declaration blanket waivers have far-reaching implications for how our long-term care facilities and production labs operate and are important to watch as the crisis unfolds. For more detailed information, see the CMS Summary.



Wednesday, 4/15/2020: CMS, Departments of Labor & Treasury issue guidance to cover diagnostic testing and other services related to COVID-19 at no cost.
After representatives of major health insurance companies committed to waive fees related to COVID-19 testing in March, the guidance, issued 4/11/2020, puts the recently passed Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act into immediate effect. The most recent guidance is centered specifically on group health plans and group and individual health insurance, in a bid to expand testing and hasten the reopening of the American economy. For further information about this guidance, see the CMS Guidance FAQ.



Monday, 4/13/2020: FCC Chairman Ajit Pai announced a new $200 Million COVID-19 telehealth program to provide immediate support for health care facilities across America.
The telehealth program also provides funding for a separate connected care pilot program to study the long-term role and effects of Telehealth on a patient population. This additional $200 comes from the approved, $100 Billion Coronavirus Aid, Relief, and Economic Security (CARES) Act and is available for distribution to industry leaders wishing to take part. For information on the COVID-19 related programs that the Small Business Administration (SBA) and the Department of Treasury are providing, please visit the Coronavirus (COVID-19): Small Business Guidance & Loan Resources website or the U.S. Department of The Treasury’s Taking Action Website.



Friday, 4/10/2020: The Centers for Medicare and Medicaid Services (CMS) recently approved an unprecedented $34 Billion through the Accelerated/Advance Payment Program for Medicare Providers to ensure resources reach the frontlines of the battle against COVID-19.
In response to our healthcare provider’s developing needs, CMS streamlined their approval process to better handle the more than 25,000 new funding requests during the week of 3/30/2020. Since then, more than 17,000 requests have been approved, opening the door for billions more in funding, separate from the $100 Billion approved in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The Department of Health and Human Services (HHS) will soon provide additional resources for healthcare providers and suppliers who wish to access CARES Act funds, while CMS has provided an important Fact Sheet (PDF) regarding accelerated/advance payment processes.



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