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September 14, 2020


SNF Outbreak Testing Clarification. One positive test among staff or residents in a SNF constitutes an outbreak, according to both the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS). According to the recently-published CMS guidelines on testing in SNFs, all residents and staff in a building that experiences an outbreak must be tested as soon as possible, with follow-up testing at a prescribed interval. These are the basic rules with which SNF providers have become familiar over the past two weeks. There are two exceptions, though, that are worth understanding because they can limit the circumstances under which a positive test result triggers outbreak testing.

  • Positive antigen tests. Under the CDC guidance entitled, "Considerations for Use of SARS-CoV-2 Antigen Testing in Nursing Homes" (and the accompanying CDC algorithm), if the positive is from a point-of-care antigen test of a person without COVID-19 symptoms, a confirmatory polymerase chain reaction (PCR) test should be done within 48 hours. CDC only calls for initiating outbreak procedures if the PCR test is positive. If it is negative, CDC suggests consulting with local public health authorities for guidance. While the CMS guidelines do not specifically refer to these CDC materials, they clearly represent CDC's current thinking on how antigen test results relate to outbreak testing, presumably because of the increased possibility of false positives.
  • Nursing home onset. The CMS guidelines state that to trigger outbreak testing, a positive must be considered to be of "nursing home onset." This term is defined in another CDC guideline, "Testing Guidelines in Nursing Homes," which in this case carries a specific reference in the CMS guidance. CDC provides this definition:

Nursing home-onset SARS-CoV-2 infections refers to SARS-CoV-2 infections that originated in the nursing home. It does not refer to the following:

  • Residents who were known to have COVID-19 on admission to the facility and were placed into appropriate Transmission-Based Precautions to prevent transmission to others in the facility.
  • Residents who were placed into Transmission-Based Precautions on admission and developed SARS-CoV-2 infection within 14 days after admission.
So, under these exceptions, not all positives among SNF staff or residents are considered outbreaks. Unconfirmed positive antigen tests and positive tests in new admissions under the conditions specified in the CDC guidelines, which are required for all admissions under other CDC guidance, are not.

Private-Pay Assisted Living PRF Deadline Reportedly Extended; Phase 3 Coming. Contrary to previous representations by the Department of Health and Human Services (HHS), NCAL reported today that HHS extended to September 21 the deadline for private-pay assisted living communities to apply for Provider Relief Fund (PRF) dollars in the Phase 2-General Distribution. At this time, the extension does not appear to be mentioned on HHS's PRF web page or in the linked documents. NCAL does not believe the extension applies to other types of applicants originally included in Phase 2 (e.g., Medicaid-only providers). HHS reportedly allowed the extension because it is not yet ready to roll out Phase 3, which will allocate funding to providers for whom other distributions did not cover their lost revenue and increased costs during the first two quarters of 2020. Like Phase 2, Phase 3 will require an application, this time showing the increased costs and lost revenue and the amounts received under Phases 1 and 2, as well as from state relief efforts such as Ohio's Coronavirus Relief Fund outlays.

CMS to Withdraw MFAR. In a bit of good news this afternoon, CMS Administrator Seema Verma tweeted that the agency will withdraw the Medicaid Financial Accontability Regulation (MFAR) proposed last November. Although CMS had not finalized MFAR, the rule hung heavily over the heads of states with budgets already hammered by COVID-19. MFAR sought to eliminate or to restrict drastically various Medicaid funding mechanisms, such as intergovernmental transfers and provider taxes, relied upon by many states. Ohio would not have been hit as hard by MFAR as some states, but the proposal created some risk for Ohio's SNF provider tax, which generates about $1.1 billion annually for the state Medicaid program and helps underwrite SNF rates.

Abbott BinaxNOW Testing Cards On the Way. Per a notice from CMS that some facilities received this evening, HHS is shipping them Abbott BinaxNOW cards this week. HHS's Admiral Brett Giroir predicted last week that this would occur. As it is breaking news, we are not sure if HHS is sending the cards to assisted living communities as well as SNFs. The notice would suggest that is the case, as it mentions both. The cards are COVID-19 antigen tests that do not require a machine to read. Nonetheless, only facilities with Clinical Laboratory Improvement Amendments (CLIA) Certificates of Waiver can use the cards, and presumably they are subject to the CLIA reporting requirements. The notice states that the cards will be shipped this week through December 20, 2020. Relative to the method of allocating the cards, the notice specifies:

Distribution of tests are prioritized based on Centers for Disease Control and Prevention (CDC) epidemiological hotspot data. Facilities with a high incidence of cases will be prioritized to receive the first waves of shipments. Hotspot data will be reevaluated on a monthly basis to determine prioritizations. Nursing homes and assisted living facilities in areas with greater than 10% positivity (red counties) and those in areas with 5-10% positivity (yellow counties) will be prioritized.

  • Red counties: test allocation for testing of all staff 2x/week.
  • Yellow counties: test allocation for testing of 50% of staff 1x/week.

The cards appear to be coming in pallets of 6,400 tests each, one per facility regardless of size, but that is not altogether clear in the notice.

DODD COVID-19 Website. The Department of Developmental Disabilities (DODD) launched a new webpage that reorganizes all the department's various COVID-19-related guidance. The webpage breaks out the guidance by type of provider (ICF, Waiver, Adult Day, and County Boards) and then by subject matter.