COVID-19: New Waiver Allows OT to Open HHA Cases

Thoughtware Alert Published: Apr 22, 2020
Healthcare Event

On April 9, CMS temporarily suspended certain regulatory requirements through 1135 waivers so healthcare facilities can increase their frontline medical staff during the SARS-CoV-2 virus and incidence of COVID-19 (COVID-19) public health emergency. This is a new blanket waiver for home health agencies (HHA) in addition to the those described in a recent BKD Thoughtware® alert, “COVID-19: What HHAs Need to Know Now Regarding New Regulations, Waivers & Flexibilities.”

The Waiver

Allow occupational therapists (OT) to perform the initial and comprehensive assessments for all patients (42 CFR 484.55(a)(2) and 484.55(b)(3)). CMS is waiving the requirement that OTs may only perform the initial and comprehensive assessments if occupational therapy is the service that establishes the patient’s eligibility to receive HHA services. This temporary blanket waiver allows OTs to perform the initial and comprehensive assessments for all patients receiving therapy services as part of the plan of care, to the extent permitted under state law, regardless of whether occupational therapy is the service that establishes eligibility. The existing regulations at Section 484.55(a) and (b)(2) would continue to apply that OTs and other therapists wouldn’t be permitted to perform assessments in nursing-only cases. HHAs are expected to continue to match the appropriate discipline that performs the assessment to the patient’s needs to the greatest extent possible. Therapists must act within their state scope of practice laws when performing initial and comprehensive assessments and access a registered nurse or other professional to complete sections of the assessment that are beyond their scope of practice. Expanding the category of therapists who may perform initial and comprehensive assessments to include OTs provides HHAs with additional flexibility that may decrease patient wait times for the initiation of HHA services.


According to CMS’ Conditions for Coverage, occupational therapy doesn’t qualify, or establish eligibility, for HHA coverage as a standalone service. Once the patient meets qualifying criteria by virtue of needing skilled nursing on an intermittent basis, physical therapy or speech-language pathology, then occupational therapy is a covered, skilled service for continued need after the qualifying discipline has initiated service. Furthermore, the home health Conditions of Participation require that the only disciplines permitted to perform the initial and comprehensive assessment are the services that establish eligibility for the patient to receive HHA services. This is the requirement being waived.

The patient must receive initiating orders for a qualifying discipline for an OT to perform the initial or comprehensive assessment, whether or not occupational therapy is on the order.

The qualifying service requirement was designed to include only those disciplines that had their own state licensing and oversight in all states, which at the time the Medicare benefit was written didn’t include occupational therapy. Occupational therapy now has practice acts in all 50 states, and the American Occupational Therapy Association (AOTA) has long advocated for occupational therapy to become a qualifying discipline. In 2008, AOTA advocacy resulted in the Home Health Flexibility Act (Act) to give HHAs the flexibility of OTs performing initial and comprehensive assessments once the patient meets qualifying criteria for HHA services. While the Act wasn’t enacted, the CMS waiver accomplishes this very flexibility.

What Happens Now

There will be OTs who need education and training for conducting comprehensive assessments and the Outcome and Assessment Information Set. CMS’ Home Health Quality Reporting Program webpage provides abundant opportunities for education depending on where an OT needs to start, e.g., at the very beginning or just an update. There also are multiple other sources for education provided by a number of education vendors and AOTA.

Because occupational therapy care focuses on activities of daily living (ADL), another advantage of using OTs to perform the initial and comprehensive assessments besides a timelier initiation of care includes using the OT’s expertise to help develop a care plan that prioritizes what’s most important to the patient by focusing on the patient’s ADLs.

As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication. For more information, reach out to your BKD Trusted Advisor™ or use the Contact Us form below.

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