DHS COVID-19 PROVIDER RESOURCES // OLTL
Temporary Changes to the OBRA 1915(c) Waiver
Issued: March 23, 2020; Updated: May 8, 2020
Service Coordinators and Providers in the OBRA Waiver
The Centers for Medicare & Medicaid Services (CMS) approved the following temporary
changes to the OBRA 1915(c) waiver from March 6, 2020 through June 30, 2020.
Approval of these changes is covered under Appendix K, Emergency Preparedness and
Response, which states may use during emergency situations to request amendments
to their approved waivers. These changes address potential staffing shortages and the
need for service provision not included in approved service descriptions to ensure
participant health and safety needs can be accommodated for the duration of the
COVID-19 statewide emergency. The duration of the approval may be extended
depending on the length of the declared emergency.
The changes outlined below provide flexibilities for Service Coordinators and providers
as they work with participants who may be facing disruption in services due to COVID19. The flexibilities outlined below will not apply to all participants and should not be
considered across-the-board changes that must be implemented for each participant.
These flexibilities must be evaluated on a case-by-case basis in coordination with
the Service Coordinator and the Office of Long-Term Living (OLTL) Participant
Services Review Unit. Service Coordinators should contact RAPWURGENTREVIEW@pa.gov for service plan issues related to the Appendix K
Guidance for Determining Whether the Amendments in Appendix K Apply
All changes authorized by Appendix K, as explained below, may only be implemented for participants impacted by COVID-19. The following questions can be used to determine whether requests and authorizations will be covered under Appendix K:
What change occurred for the participant as a result of COVID-19?
- Was the participant receiving services in a setting that closed?
- Has the participant tested positive for COVID-19 that requires relatives to render services when direct care workers are unwilling or unable to render services while the participant remains positive for COVID-19?
- Has the participant’s caregiver or a person with whom they live tested positive for or exhibited symptoms of COVID-19?
- Has the participant’s direct care worker tested positive for or exhibited symptoms of COVID-19?
Is the participant’s direct care worker isolating at home or quarantined due to exposure to someone who tested positive or exhibited symptoms of COVID-19?
- Is the participant’s direct care worker unable to render services due to caring for a child or children due to closure of schools or day care programs as a result of COVID-19?
- Is the participant’s direct care worker unable to render services due to caring for a family member who tested positive for or exhibited symptoms of COVID-19?
- Is the provider unable to provide staffing at pre-COVID-19 required levels due to overall shortages of staffing and inability to secure additional staff?
General Billing Guidance
On February 20, 2020, the Centers of Disease Control and Prevention (CDC) issued
official diagnosis coding guidance for health care encounters related to COVID-19. View the
Based on this guidance, when services are related to COVID-19, providers and Service
Coordinators must use the following ICD-10-CM billing codes –
Z03.818 - Encounter for Observation for Suspected Exposure to Other Biological
Agents Ruled Out, for claims where there is a concern about a possible exposure to
Z20.828 - Contact with And (Suspected) Exposure To Other Viral Communicable
Diseases, where there is an actual exposure to someone who is confirmed to have
Example #1: If a participant’s spouse temporarily serves as a paid direct care worker
because the scheduled worker is suspected of having been exposed to COVID-19 (and
a replacement worker is not available), the provider must use Z03.818 in addition to the
primary diagnosis code used when billing for HCBS services.
Example #2: If a participant’s spouse temporarily serves as a paid direct care worker
because the scheduled worker has tested positive for COVID-19 (and a replacement
worker is not available), the provider must use Z20.828 in addition to the primary
diagnosis code used when billing for HCBS services.
- Providers and Service Coordinators must bill the applicable procedure and place of
service codes and include the appropriate COVID-related ICD-10 diagnosis code, in addition to the primary diagnosis code, to indicate service, setting or staffing
exceptions that are approved in Appendix K.
- When temporary Appendix K changes are implemented as a precautionary
measure to protect a participant, even when there is no concern for possible
exposure, providers and Service Coordinators must use Z03.818 in addition to the
primary diagnosis code used when billing for HCBS services.
- Where a participant is exposed to or tested positive for COVID-19, providers and
Service Coordinators must use Z20.828 in addition to the primary diagnosis code
when billing for all HCBS services, not just those approved in Appendix K.
- For services provided on or after March 6, 2020, providers and Service Coordinators
should resubmit any claims that are not in compliance with this billing guidance.
- Providers must contact the participant’s Service Coordinator to communicate
changes to services or settings.
- If a provider decides to change their business practice, e.g., modifying staffing ratios,
limiting services or suspending services, the provider must contact OLTL’s
enrollment team at RA-HCBSEnProv@pa.gov before making the change.
For all waiver services — services may not be reduced on the Person-Centered Service Plan (PCSP), except when requested by the participant or their representative. However, it is possible that not all services on the PCSP can be delivered during the COVID-19 emergency declaration. Providers should be given flexibility to ensure delivery of crucial, life-sustaining services and, if necessary, delay less crucial services such as housekeeping tasks. The CHC-MCOs may need to identify and prioritize services to participants with critical issues and at the same time allow for missed shifts for participants who have adequate informal supports or less-critical issues.
Personal Protective Equipment (PPE) such as gloves, gowns and masks for participant use can be obtained as Specialized Medical Equipment and Supplies if no other source is available. PPE may be added to a participant’s PCSP without the need for a comprehensive needs assessment or a physician’s prescription. Use of PPE is not required or appropriate for every participant. Purchase and utilization of PPE must be in accordance with CDC guidelines and CHC-MCO guidance.
For the following services, service limitations are temporarily lifted during the COVID-19 emergency declaration:
- Adult Daily Living Services (upon reopening of adult day centers) — Normally, Long-Term or Continuous Nursing cannot be provided simultaneously with Adult Daily Living Services. Temporarily, Long-Term or Continuous Nursing may be provided as a separate service at the same time that Adult Daily Living Services are provided to ensure participant health and safety needs can be met.
- Residential Habilitation — Normally, licensed settings serving participants may not exceed a licensed capacity of more than 8 unrelated individuals. Temporarily, service definition limitations on the number of people served in each licensed home may be exceeded, provided that the number of participants can be safely served in the setting.
Normally, Long-Term or Continuous Nursing and Residential Habilitation cannot be on a PCSP at the same time. Temporarily, Long-Term or Continuous Nursing may be provided as a separate service at the same time that Residential Habilitation is provided to ensure participant health and safety needs can be met.
- Personal Assistance Services (Agency and Participant-Directed) and Participant-Directed Community Supports — Normally, some family members can provide Personal Assistance Services and Participant-Directed Community Supports, with exceptions.
Temporarily, spouses, legal guardians, and persons with power of attorney may serve as paid direct care workers only when scheduled workers are not available due to COVID-19 and the participant’s emergency backup plan cannot be implemented. Spouses, legal guardians and persons with power of attorney will be allowed to serve as paid direct care workers only until a replacement direct care worker is in place and in no case beyond the duration of the COVID-19 emergency declaration.
This temporary flexibility does not apply in circumstances where a participant or their representative refuses services due to COVID-19 safety concerns despite the direct care worker(s) being available to provide services.
Under the participant-directed model, spouses, legal guardians and persons with power of attorney must be enrolled as direct care workers through PPL and undergo criminal background checks and child abuse clearances as required by law.
For agency employees, background checks and child abuse clearance requirements must be performed as required by law.
- Expanded Settings Where Services May Be Provided
Expanded Settings Where Services May Be Provided
- Residential Habilitation and Structured Day Habilitation Services - may be
provided to participants by Residential Habilitation and Structured Day
Habilitation staff in private homes.
- Structured Day Habilitation – may be provided remotely using phone or video
conferencing only to participants who received the services face-to-face prior to
the COVID emergency declaration.
- Cognitive Rehabilitation and Behavior Therapy – may be provided remotely
using phone or video conferencing only to participants who received the services
face-to-face prior to the COVID-19 emergency declaration.
- Counseling Services – may be provided remotely using phone or video
Modification of Worker Qualifications
- Residential Habilitation, Structured Day Habilitation Services, Adult Daily Living (upon reopening of adult day centers), and Personal Assistance Services — Individual staff members who are qualified to provide any one of these services may be reassigned to provide Residential Habilitation, Structured Day Habilitation Services, Adult Daily Living, and Personal Assistance Services.
All staff should receive training on the PCSP of the participant for whom they are providing support. Training on the PCSP must consist of basic health and safety support needs for that individual.
Modification of Licensure or Other Requirements for Settings Where Waiver Services are Furnished
Licensed Residential Habilitation, Structured Day Habilitation Services and Adult Daily Living (upon reopening of adult day centers) — Maximum number of individuals served in a service location may be exceeded to address staffing shortages or accommodate use of other sites as quarantine sites. For example, a provider operates 4 residences, with 8 participants residing in each location. Per usual waiver limits, the maximum is 8 participants in a setting. Due to staff illness, the provider does not have adequate staff to cover all 4 residences. The provider may temporarily close one location and disperse the participants among the remaining 3 locations if the locations have sufficient room to accommodate additional participants. The new temporary arrangement would be 11 participants each in residences 1 and 2, and 10 participants in residence 3.
Minimum staffing ratios as required by licensure, service definition or the participant’s PCSP may be exceeded due to staffing shortages.
Note: These modifications do not apply to unlicensed Residential Habilitation settings, which cannot exceed the usual maximum number of participants per residence and staffing ratios.
Level of Care Assessments and Needs Assessments/Reassessments
- Initial Level of Care Assessments using the FED — may be conducted remotely using phone or video conferencing; the face-to-face requirement is temporarily waived.
- Annual Reassessments, including the needs assessment and level of care - may be conducted remotely using phone or video conferencing; the face-to-face requirement is temporarily waived. The 365-day time limit for annual reassessments to be performed is also temporarily waived. If a reassessment is going to be delayed beyond 365 days, the Service Coordinator must contact the participant at least 30 days prior to the normal reassessment due date to verify with the participant or representative that the current PCSP, including services and providers, remains acceptable for the upcoming year. If necessary, the Service Coordinator will ensure the PCSP is modified to allow for additional supports and/or services due to changes in participant needs. If no updates to the participant’s PCSP are needed due to COVID-19 or a change in the participant’s needs that require an increase in services, the existing PCSP will remain in place until the annual reassessment can be completed. At the end of the COVID-19 emergency declaration, the Service Coordinator will have up to 6 months to complete the annual reassessment and update the PCSP.
- Comprehensive Needs Reassessments - may be conducted remotely using phone or video conferencing when a participant’s needs change, when the participant requests a reassessment, or following trigger events. The qualifications for the individuals conducting these assessments will not change.
No Visitor Policies
- Provider-owned and -operated settings where waiver services are provided – may prohibit or restrict visitation in line with CMS recommendations for longterm care facilities. This modification is not required to be justified in the PCSP
Incident Management Reporting Requirements
- Critical Incident Reports — The CHC-MCO and providers must submit critical incident reports for Service Interruptions even if the reason for the Service Interruption is due to insufficient staff to provide care due to COVID-19.
- Critical Incident Investigations — The CHC-MCO will not need to conduct an investigation for Service Interruptions when the Service Interruption is due to insufficient staff to provide care due to COVID-19. The CHC-MCO must ensure that participants at highest risk continue to receive services.
Retainer Payments to Address Emergency Related Issues
- Personal Assistance Services – During the COVID-19 emergency, retainer payments to direct care workers in agency and participant-directed models may be made when the participant is hospitalized, absent from their home, or in isolation and unable to receive services due to COVID-19. Personal Assistance Services retainer payments may not exceed 15 days – the number of days for which OLTL authorizes a payment for "bed-hold" in nursing facilities. Retainer payments will not be available when another reasonably equivalent assignment is made available to a direct care worker or when the worker is laid off and collecting unemployment. CHC-MCOs will provide additional guidance to agencies and workers regarding these retainer payments.Authorization for Changes to the PCSP
- Billing Guidance
- Providers must bill the applicable procedure code (W1792, W1793,
W1792 TU) and must only be billed with the COVID-19 ICD-10 diagnosis
- Providers should bill for the scheduled hours during the time the
participant is hospitalized or absent from their home. For example, if the participant is hospitalized for COVID-19 and was scheduled for 5 hours of
Personal Assistance Services for 8 of the 15 consecutive calendar days,
the provider would bill for 40 hours (5 hours x 8 days)
Authorization for Changes to the ISP
- Verbal and Email Approval – If delays are occurring while waiting for
approval and authorization of ISP changes in HCSIS, documented verbal
approval or email approval of changes and additions to ISPs will suffice as
authorization. Upon validation that a verbal or email approval was provided
for requested changes, Service Coordinators may backdate authorizations for
Documenting what actions were taken and maintaining evidence for why actions were taken.
In addition to notifying the CHC-MCO, a provider should document any changes to their operations as a result of COVID-19 and maintain evidence to support why the changes were made. Doing so will help demonstrate the basis for an action. In general, evidence that should be maintained includes, but is not limited to:
- Orders or notices from Federal, State, and local authorities that support changes to operational procedures.
- Correspondence and other records demonstrating inability to meet required staffing ratios or response times. Example: Provider’s employees are unable to report to work due to COVID-19-related reasons. Provider attempts to secure temporary staff from three staffing agencies, but each agency reports that they too are experiencing staff shortages. As a result, Provider is out of compliance with required staffing ratios. Provider should maintain documentation of employee unavailability and retain copies of correspondence with each of the three staffing agencies to demonstrate that all possible efforts were made to secure enough staff.
- Records demonstrating changes made in staffing or location of service provision. Example: Provider temporarily closes its Structured Day Habilitation Program and reassigns staff to provide services to participants in their homes. The provider should retain a copy of this notice, documentation of staff reassignments and steps taken to ensure reassigned staff have required training to ensure health and safety support of the participant.
- Document all services performed to include but not limited to:
- Participant name
- Participant date of birth
- Date of service
- Services performed
- Start and stop times of the services performed
- Individual performing the services
- Service location
- Providers should maintain fiscal records in accordance with 55 Pa. Code §§ 52.15 and 1101.51 to document service delivery and claims submissions.