Updated on 07/06/2022

The National Association for Home Care & Hospice (NAHC) and a group of likeminded organizations have written to Brian Slater, Director of the Division of Home Health and Hospice in the Center for Medicare Centers for Medicare & Medicaid Services (CMS) to reiterate our strong support for the authority of nurse practitioners (NPs) and clinical nurse specialists (CNSs) to order and certify home health services for Medicare beneficiaries.

NAHC is engaged in an ongoing dialogue with CMS to ensure any future agency guidance reflects the legislative intent of the CARES Act to improve access to home health care services for Medicare beneficiaries. It is imperative that the language does not restrict access to these important services.

Section 3708 of the Coronavirus Aid, Relief and Economic Security Act (CARES Act) authorized NPs, CNSs and PAs to order and certify home health services. We appreciate that pursuant to the passage of the CARES Act, CMS took swift action to implement these changes through rulemaking. The ability of NPs to order home health services has been instrumental to ensuring beneficiaries receive the necessary services and care, especially throughout COVID-19 Public Health Emergency (PHE). This is especially important as NPs continue to provide an increasing amount of care to Medicare beneficiaries. As of 2020, there were over 177,000 NPs billing for Medicare services, making NPs the largest and fastest growing Medicare designated provider specialty. Approximately 40% of Medicare patients receive billable services from a nurse practitioner, and approximately 80% of NPs are seeing Medicare and Medicaid patients.

Section 3708 of the CARES Act reads that “NPs, CNSs, and PAs would be able to practice to the top of their state licensure to certify eligibility for home health services, as well as establish and periodically review the home health plan of care.” Since CMS implemented these changes, NAHC members have overwhelmingly reported positive feedback on the impact they have had on patient access to care. Additionally, the vast majority of states have updated any regulations that were inconsistent with this authority.

The regulations promulgated by CMS streamlined the home health care process, and reduced delays in care which often impacted the most vulnerable, high-risk patients. CMS and other entities have consistently recognized the importance of removing barriers to care on advanced practice registered nurses and their patients. As the Centers for Medicare and Medicaid Innovation (CMMI) notes in the ACO REACH model, removing barriers to care for nurse practitioners is critical to promoting health equity and reducing “disparities in health such that those with the greatest needs and least resources receive the care they need.5 Ensuring beneficiaries have equitable access to care is also directly embedded within multiple White House Executive Orders, the HHS Strategic Plan, and the CMS strategic plan. The National Academies of Science, Engineering and Medicine Future of Nursing 2020-2030 report also recommends that “all relevant state, federal and private organizations enable nurses to practice to the full extent of their education and training by removing practice barriers that prevent them from more fully addressing social needs and social determinants of health and improve health care access, quality, and value.”

As the Division of Home Health and Hospice considers possible further sub-regulatory guidance, NAHC will be working  to ensure it does not restrict access to care by placing burdensome requirements on NPs and CNSs ordering home health care. NAHC appreciates withdrawal of the previous guidance, at our urging, which caused confusion and delay. NAHC is determined that any future guidance will ensure equitable access to home health services and we will continue to work cooperatively with the Division of Home Health and Hospice to see this done.

Article published by NAHC on July 6, 2022
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