The COVID-19 public health emergency continues to pose new and unprecedented challenges for our health-care system and individual physicians and practices. APMA is here to help its members navigate these difficult times and continue to deliver the highest-quality foot and ankle care to patients. This section provides a wealth of resources for everything from clinical concerns to practice management and financial guidance.

Frequently Asked Questions

APMA has compiled answers to members' frequently asked questions.

FAQ

APMA Recommendations

• Consider providing telehealth services to your patients.
• Encourage eligible patients to get vaccinated! Learn more about vaccine recommendations. 
• Check our COVID-19 resource page and FAQ frequently for updates and new resources, including information to share with your patients.
• Stay up to date on the CDC's latest guidance for health-care professionals. 

Page Updated December 1, 2021

In response to the COVID-19 pandemic, the CARES ACT expanded loan options for small businesses, and we expect podiatric offices to take advantage of one or both loan options. Detailed information about both options is available on this page.

• Paycheck Protection Program (PPP)–Purpose is to help small businesses with their payroll and related costs for an eight-week period. Loan forgiveness available for small businesses that maintain their workforce. 
• Economic Injury Disasters Loan and Loan Advance (EIDL)–Program provides small businesses with working capital loans of up to $2 million that can provide vital economic support to small businesses to help overcome the temporary loss of revenue they are experiencing. Small businesses can access a $10,000 loan advance that is not repaid.

Jump to a section
Paycheck Protection Program
Economic Injury Disasters Loan and Loan Advance
Marcum, LLP Articles for Podiatric Practices
Additional Assistance and Resources
Webinar: How Your Practice Can Survive COVID-19
Podcast: Applying for SBA Loans

Paycheck Protection Program (PPP) - Closed as of May 31, 2021

As part of the CARES Act and the second December 2020 $900 billion COVID relief package, Congress provided the initial round and second round of PPP loans that were available to small businesses impacted by the COVID-19 crisis. Eligible entities for both rounds included:

• Small businesses; 
• self-employed individuals; 
• sole proprietors; and 
• independent contractors. 

	Summary
First Draw PPP Loans (FDLs) ($10 Million)	The eligible entity must be 500 employees or fewer.
Second Draw PPP Loans (SDLs) ($2 Million)	The eligible entity must be 300 employees or fewer and have already received a first draw PPP loan. The eligible entity must also demonstrate at least a 25 percent reduction in the first, second, or third quarter relative to the same 2019 quarter. If a business was not in operation in 2019, the Act provided applicable timelines for demonstrating a loss.  An eligible entity may only receive one PPP second draw loan. For loans of $150,000 or less, the entity could have submitted a certification attesting that the entity meets the revenue loss requirements on or before the date the entity submits its loan forgiveness application.

Loan Forgiveness

FDL and SDL PPP borrowers may receive a loan amount of up to 2.5 times their average monthly payroll costs (capped at $100,000 per employee annualized), in 2019, 2020, or the year prior to the loan. The maximum loan amount is $10 million for first-time borrowers and $2 million for second-time PPP borrowers. Both first and second draw loans are forgivable if the funds are used on the following eligible costs:

• payroll
• rent
• covered mortgage interest
• utilities
• covered worker protection and facility modification expenditures
• covered property damage costs
• covered payments to suppliers and payments for business software or cloud computing services that facilitate business operations
• product or service delivery
• back-office functions, including accounting

To be eligible for full loan forgiveness, PPP borrowers must spend no less than 60 percent of the funds on payroll over a covered period of their choice between eight and 24 weeks.

• Review the FAQ to find out how to calculate your maximum loan amount
• Review the FAQ to learn what is included in the payroll costs
• Watch a video from our partner, Bankers Healthcare Group, about how to prepare for loan forgiveness
• Read an article from Bankers Healthcare Group to learn more about loan forgiveness

In the December 2020 COVID-19 relief package, Congress also addressed the following:

• clarified the tax treatment for PPP loans, specifically that gross income doesn’t include any forgiven portion of the PPP loan and deductions are allowed for otherwise deductible business expenses when paid using PPP funds that are forgiven;
• removed the previous requirement to deduct the EIDL Advance from the total PPP forgivable amount;
• expanded and clarified eligible non-payroll expenses, made effective to the date of the CARES Act;
• extended the covered period for all PPP loans through March 31, 2021, applying to loans made before, on, or after the date of enactment, including the forgiveness of such loan. 
• increased the ability for PPP borrowers to request an increase in loan amount due to updated regulations, allowing borrowers who returned all or part of their PPP loan to reapply for the maximum amount applicable, so long as they have not already received forgiveness; and
• directs a simplified forgiveness application to be provided for loans of $150,000 or less.

FDL and SDL forgiveness: 

Recipients of both first draw and second draw loans would be eligible for forgiveness equal to the sum of their payroll costs, as well as covered mortgage, rent, and utility payments, covered operations expenditures, covered property damage costs, covered supplier costs, and covered worker protection expenditures incurred during the covered period. The 60/40 cost allocation between payroll and non-payroll costs in order to receive full forgiveness will continue to apply.  

Borrowers should contact their lenders for additional information on the loan forgiveness process.

Forgiveness Application:

There are two loan forgiveness applications, dependent on how much money your practice received:

1. PPP loans of $50,000 or less - PPP Loan Forgiveness Application Form 3508S
   For this simpler application, fewer calculations and less documentation is required for eligible borrowers. Borrowers who use SBA Form 3508S are exempt from reductions in loan forgiveness amounts based on reductions in full-time equivalent (FTE) employees or in salaries or wages. SBA Form 3508S also does not require borrowers to show the calculations used to determine their loan forgiveness amount. However, SBA may request information and documents to review those calculations as part of its loan review process. Read the full instructions here.
2. PPP loans of more than $50,000 - PPP Loan Forgiveness Application Form 3508
   For this loan application, there are four components: 1) the PPP Loan Forgiveness Calculation Form; 2) PPP Schedule A; 3) the PPP Schedule A Worksheet; and 4) the (optional) PPP Borrower Demographic Information Form. All borrowers must submit (1) and (2) to their lender. Options are available for borrowers to calculate payroll costs using an “alternative payroll covered period” that aligns with borrowers’ regular payroll cycles. Flexibility exists to include eligible payroll and non-payroll expenses paid or incurred during the eight-week period after receiving the PPP loan. For loans made before June 5, a borrower may elect an eligible period of eight weeks. For all other loans, the eligible period is 24 weeks or until December 31, 2020, whichever comes first. Read the full instructions here.

APMA encourages borrowers to contact their accountants to assist with preparing the appropriate documentation. There is no explicit deadline for submission, PPP loan recipients should contact their lender directly for information on submitting the loan forgiveness application.

Critieria:

• You must submit a request for loan forgiveness with the lender that is servicing the loan.
• Include documents that verify the number of full-time equivalent employees and pay rates.
• Include payments on eligible mortgage, lease, and utility obligations.
• Lender must make a decision within 60 days.

Forgiveness Amount:

• The loan will be fully forgiven if the funds are used for payroll costs, interest on mortgages, rent, and utilities. At least 60 percent of the funds must be used for payroll costs.
• Forgiveness will be reduced if full-time headcount is reduced.
• Forgiveness will be reduced if you decrease salary and wages by more than 25 percent for any employee who made less than $100,000 annualized in 2019.

NOTE: Borrowers had until December 31, 2020, to restore their full-time employment and salary levels for any changes made between February 15 and April 26, 2020. 

The PPP Flexibility Act added additional exemptions to the reduction in the amount of loan forgiveness. Under the new law, the amount of loan forgiveness will not be reduced based on a reduction in the number of full-time equivalent employees if the borrower, in good faith:

• can document that the borrower is: i) unable to rehire individuals who were employees of the borrower on February 15, 2020; and ii) unable to hire similarly qualified employees for unfilled positions on or before December 31, 2020; or
• can document an inability to return to the same level of business activity as that which existed prior to February 15, 2020, due to compliance with COVID-related health and safety guidance (e.g., standards for sanitation or social distancing) during the period from March 1, 2020 through December 31, 2020.

Loan Terms
Borrowers may owe money when their loan is due if they use the loan amount for anything other than payroll costs, mortgage interest, rent, and utilities payments after receiving the loan. Borrowers will also owe money if they did not maintain their staff and payroll. If any or portion of the loan is not forgiven, these loan terms apply for all borrowers. 

• 1.0-percent fixed interest rate
• Loans issued after June 5 have a 5-year maturity time period and loans issued before then are due in two years unless the lender and borrower agree to new terms.
• Lenders are required to provide complete payment deferment relief for “impacted borrowers” until the loan forgiveness is determined or in ten months if the loan forgiveness application is not submitted within ten months of the loan origination date. This includes interest and fees. Impacted borrowers are presumed to have been impacted adversely by COVID-19, and all recipients are presumed to be “impacted borrowers.”

Changes in Ownership if Owner has received a PPP Loan

On October 2, 2020, the SBA also released additional guidance on whether or not the SBA needs to approve any change in ownership. The SBA clarified that for 7(a) loans made under the PPP, no approval is required if the borrower has repaid its PPP loan in full or if it has applied for forgiveness with a final determination on forgiveness having been made (as evidenced by the SBA's payment to the lender) with either the full amount of the loan forgiven or the borrower having repaid any unforgiven amount.

If you have PPP amounts outstanding, it depends on several factors.

1. SBA approval is not required in the event of (i) transfer (including through merger) of 50 percent or less (when combined with all other transfers occurring since the date of approval of the borrower's PPP loan) of the ownership interests in the borrower, or (ii) the borrower submits a completed forgiveness application to its lender and escrows the full amount of the PPP loan with the lender. In the latter case, the amount escrowed must be used to repay any unforgiven portion of the PPP loan.
2. SBA approval is not required in the event of (i) transfer of less than 50 percent of the assets of the borrower, or (ii) the borrower submits a completed forgiveness application to its lender and escrows the full amount of the PPP loan with the lender. In the latter case, the amount escrowed must be used to repay any unforgiven portion of the PPP loan.

The borrower must seek approval of the SBA before effectuating any other ownership change, regardless of whether it is an equity or asset sale. As part of the approval process, the borrower must submit certain information to the SBA (through its lender), including the following:

• A statement of why the borrower is unable to structure the transaction so as to satisfy the requirements for a transfer without SBA approval, including a statement why any required escrow cannot be funded from proceeds of the transaction.
• The details of the proposed transaction, including a copy of any letter of intent or purchase agreement relating to the transaction.
• Disclosure of any PPP loans held by the transferee(s) prior to the proposed transaction.
• A list of all owners of 20% or more of any transferee entity.

The SBA will issue a determination within 60 days of the receipt of a complete request.

Additional Resources from APMA Partners

• Hart Health Strategies Fact Sheet Small Business Paycheck Protection Program
• Hart Health Strategies PPP FAQ
• Foley & Lardner Key Changes to the PPP Flexibility Act
• Foley & Lardner Top 10 Insights from the SBA’s PPP Loan Forgiveness Application
• Capitol Hill Consulting Group COVID-19 Healthcare Funding Opportunities

Paycheck Protection Program (PPP) FAQ

Economic Injury Disaster Loan (EIDL) and Emergency EIDL Loan Advance

Eligibility

EIDLs are available to small businesses, independent contractors, and sole proprietors in declared disaster areas, which now includes all 50 states and territories. To qualify for an EIDL, the applicant must have suffered “substantial economic injury” from COVID-19. Substantial economic injury generally means a decrease in income from operations or working capital with the result that the business is unable to meet its obligations and pay ordinary and necessary operating expenses in the normal course of business.

Loan Amount
Eligible recipients can receive up to $2 million in assistance, which can include a $10,000 Emergency EIDL (cash advance grant). EIDL loans under the CARES Act are based on a company’s actual economic injury determined by the SBA (less any recoveries such as insurance proceeds)

Loan Forgiveness
Unlike PPP, EIDLs generally do not have any loan forgiveness provisions. However, applicants that already applied for an EIDL loan can refinance their EIDL under the PPP. Additionally, the Emergency EIDL loan (next section) of up to $10,000 is not expected to be repaid, even if you are subsequently rejected for an EIDL. 

$10,000 Emergency EIDL (Cash Advance Grant)

• How do I apply for this grant?
  The SBA has launched a streamlined application process via its website, so small businesses can submit applications for both the EIDL and Emergency EIDL simultaneously. If you had previously submitted an application for an EIDL prior to the emergency loan’s availability, you can still submit an application for the Emergency EIDL.
• How much?
  Up to $10,000 in a cash advance is available.
• How quickly can I receive this money?
  The SBA anticipates paying the cash advance within three days of a successful application. 
• What can I use the emergency EIDL cash advance for?
  The grant can be used to provide paid sick leave to employees; maintain payroll; meet increased production costs due to supply chain disruptions; or pay business obligations, including debts, rent, and mortgage payments.
• Is the cash advance forgivable?
  This advance is forgivable if it is spent on any of the items listed above. The emergency loan is also forgivable even if the grantee is subsequently denied an EIDL.

Loan Purpose
Proceeds of the overall EIDL may be used for:

• Payroll and other costs
• Increased costs due to supply chain interruption
• Mortgage or lease payments
• Obligations that cannot be met due to revenue loss and for other uses.

Application Dates
Applications for an EIDL and Emergency EIDL can be submitted from January 31–December 31, 2020. 

Application Procedures
Eligible small businesses can apply for a loan at https://disasterloan.sba.gov/ela. For questions, please contact the SBA disaster assistance customer service center at 1-800-659-2955 (TTY: 1-800-877-8339) or email disastercustomerservice@sba.gov. Eligible businesses should expect a disbursement of monies within five business days of a successful application.

Loan Terms
The interest rate on EIDL loans is 3.75 percent fixed for small businesses and 2.75 percent for nonprofits. The EIDL loans have up to a 30-year term and amortization (determined on a case-by-case basis).

Economic Injury Disaster Loan (EIDL) and Emergency EIDL (Cash Advance) FAQ

Marcum, LLP Articles for Podiatric Practices

The accounting and business advisory firm of Marcum, LLP is providing information to help podiatric practices survive during the pandemic and economic downturn and to start planning for the recovery.

Article 1: Guide to COVID-19 Small Business Loans

Article 2: Accessing Various Forms of Capital for Your Practice

Article 3: Building a Path Forward for Your Podiatry Practice

Article 4: Tools to Help Your Podiatry Practice Survive and Thrive

Additional Assistance and Resources

APMA has compiled resources on other SBA loans, state loans for small businesses, private resources and consumer assistance available to podiatric practices. 

Webinar: How Your Practice Can Survive COVID-19

APMA partnered with Marcum LLP to offer its members a one-hour webinar about recent COVID-19 legislation and resources for you and your practice. Download a copy of the presentation and a copy of the Q&A from the presentation. Marcum LLP provides a detailed guide to small business loans as an update to its How Your Practice Can Survive COVID-19 webinar.

Podcast: Applying for SBA Loans

Disclaimer: This resource is for information purposes only. APMA advises doctors of podiatric medicine to speak with an attorney or financial advisor duly licensed in their jurisdiction.

During the COVID-19 Public Health Emergency, there are four main non-face-to-face service types podiatrists can provide. A podiatrist’s ability to employ these services and be reimbursed for these services may differ based on the patient’s insurance and state licensure. Always check with payer and state licensure guidelines before providing any service.

For all of the services described below, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health-care providers who serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 emergency. 

The four main non-face-to-face service options include:

1. Telehealth — Services that are normally furnished in person which are instead furnished remotely using interactive, real-time telecommunication technology
2. Medicare Virtual Check-in
3. Telephone E/M services
4. Online digital E/M services

During the PHE, CMS and some other payers are allowing all four of these services to be provided for both new and established patients.

Additional Resources:

1. Watch a video summarizing this information
2. Listen to a podcast about this information

1. Telehealth services that are normally furnished in person which are instead furnished remotely using interactive, real-time telecommunication technology

During the PHE, CMS and some other payers are allowing certain services to be provided via telehealth  with the provider in any location and the patient in any location.

• For Medicare beneficiaries, providers can use this option for office or other outpatient evaluation and management (E&M) services (CPT® 99202–99215) and all services listed here
• Must use a communication tool that allows live, real-time interactive audio and video communication
• Providers are permitted to reduce or waive cost-sharing for these services if they wish
• Append modifier 95
• Use the Place of Service that would have been used had the service been rendered in person (e.g., POS 11 for CPT 99213 and POS 32 for CPT 99307)
• These services will be paid at the regular, in-person rate by CMS during the PHE.
• This waiver is in place as long as the PHE declaration lasts
• Postoperative global periods apply
• Does not need to be patient initiated
• Document a progress note as if this service was provided face-to-face. This interaction is an E&M service and E&M documentation requirements apply. The level is selected based on the 1995 or 1997 CMS guidelines for evaluation and management services, except when using CPT 99202-99215, in which case the level is selected based on Medical Decision Making alone or total time alone as illustrated by the AMA CPT Office or Other Outpatient E&M Guidelines.

2. Medicare virtual check-in

• G2012: Brief communication technology-based service (e.g., virtual check-in) by a physician or other qualified health-care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion
• G2252 - Brief communication technology-based service, eg, virtual check-in, by a physician or other qualified health-care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion
• Payable by Medicare Part B and Medicare Advantage
• Can be any type of telecommunication tool, including telephone
• CANNOT relate to any service in the last seven days
• CANNOT result in patient coming in within the next 24 hours or soonest available appointment
• Must be patient initiated
• No modifiers needed
• Providers are permitted to reduce or waive patient cost-sharing for these services if they wish

3. Telephone E/M services 

• This interaction is an E/M service and documentation must support an E/M just like any other E/M type. Must have history, as much of an evaluation as possible, and some form of medical management.
• Must be initiated by patient or the patient’s guardian
• Payable by Medicare and some non-Medicare payers during the PHE
• CANNOT report if call results in decision to see patient within 24 hours or next available urgent appointment
• CANNOT report if call refers to E/M service performed by same provider within previous seven days
• CANNOT report if call refers to a problem for which a patient is in a global period
• CANNOT report if provider performed a telephone E/M or online digital E/M for the same patient for the same problem in the last seven days
• CANNOT report if the call is part of Home Care Oversight Services, Care Plan Oversight Services, Home/Outpatient INR Monitoring, Complex Care Management Services, or Transitional Care Management Services
  • CPT 99441 - Telephone evaluation and management service by a physician or other qualified health-care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5–10 minutes of medical discussion
  • CPT 99442– ; 11–20 minutes of medical discussion
  • CPT 99443– ; 21–30 minutes of medical discussion

 4. Online digital E/M services 

• This interaction is an E/M service and documentation must support an E/M just like any other E/M type. Must have history, as much of an evaluation as possible, and some form of medical management.
• Examples of digital platforms:
  • Electronic health record
  • Email
  • Text message
  • Other two-way digital communication
• Must be initiated by patient via a digital platform
• Payable by Medicare and some non-Medicare payers
• Providers are permitted to reduce or waive patient cost-sharing for these services if they wish
• CANNOT report if service refers to a problem for which a patient is in a global period
• CANNOT report if service is initiated within seven days of any E/M for same problem
• CANNOT report if performed on same day as in-person E/M service
• CANNOT report if service is part of Home Care Oversight Services, Care Plan Oversight Services, Home/Outpatient INR Monitoring, Complex Care Management Services, or Transitional Care Management Services
• Time spent is cumulative time over seven days starting with review of the request
• Can only report once per seven-day period
• Time includes:
  • Review of inquiry
  • Review of patient records
  • Interaction with other staff
  • Development of management plan
  • Rx
  • Ordering tests
  • Communication with patient
• Add time if multiple providers in same practice perform this service for the same patient over the same seven-day period
• If within seven days of the initiation of an online digital E/M service, a separately reported E/M visit occurs, then the provider work devoted to the online digital E/M service is incorporated into the separately reported E/M visit
• CPT 99421: Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 5–10 minutes
• CPT 99422  ; 11–20 minutes
• CPT 99423  ; 21 or more minutes

APMA suggests obtaining informed consent for these services. APMA further suggests that members advise patients that there will be a charge for these services, that copays and deductibles may apply, and referrals may be necessary if required by the insurance plan.

5. Watch a video summarizing this information

6. Listen to a podcast about this information

We have recorded a special episode of The APMA Podcast about providing telemedicine services. Listen below.

References:

HHS Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency - https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency http://hhs.com/assets/docs/covid-final-ifc.pdf

CMS Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983–2020 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). Reference: 2020 CPT Professional

CPT codes and their descriptions do not reflect or guarantee coverage or payment. The existence of a CPT / HCPCS code does not guarantee payment for the service it describes. Coverage and payment policies of governmental and private payers vary from time to time and for different areas of the country. Questions regarding coverage and payment by a payer should be directed to that payer. APMA and its employees, consultants, and officers do not claim responsibility for any consequences or liability attributable to the use of any information, guidance, or advice contained in this communication or liability attributable to the use of any information, guidance, or advice contained in this communication.

COVID-19 Relief in the Consolidated Appropriations Act of 2021

The Consolidated Appropriations Act of 2021 includes COVID relief legislation. Read a high-level summary of provisions that may be of interest to APMA members. APMA will continue to review the legislation and provide more information to members as it becomes available.

Read Summary

CARES Act

Congress and the administration have heard from medical practices nationwide about the substantial impact of COVID-19 on their businesses. APMA’s partner, Capitol Hill Consulting Group, has created the following summary of provisions in the Coronavirus Aid, Relief, and Economic Security (CARES) Act that may have an impact for our member physicians. For more information, email advocacy@apma.org.

Read Summary

Be sure to check out APMA's eAdvocacy website to learn about legislation impacting the profession and the patients we serve, and to voice your opinion on these bills to your elected federal legislators. 

APMA has been working to protect you and your practice since the COVID-19 public health practice began. Be sure to check out APMA's eAdvocacy website to learn about legislation impacting the profession and the patients we serve, and to voice your opinion on these bills to your elected federal legislators. 

Comment Letters Related to COVID-19

• APMA Request for Clarification on PREP Act Amendment from US Department of Health and Human Services (HHS) (February 12, 2021)
  APMA wrote to HHS to seek clarification on use of "physician" as used in the Fifth Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act (PREP Act) for Medical Countermeasures Against COVID-19.
• APMA Submits Comments in Response to HHS’s Request for Information on Regulatory Relief to Support Economic Recovery (December 22, 2020)
  APMA made several recommendations including urging that HHS maintain flexibilities in its telehealth regulations once the public health emergency has ended.
• APMA Urges National Governors Association to Include Podiatric Physicians in Plans for Vaccine Distribution (December 11, 2020)
  APMA recommended that podiatric physicians be included in the first phase of vaccinations for health-care providers and be allowed to prescribe and administer the vaccine. 
• APMA Submits Comments to CMS in Response to its Third COVID-19 Interim Final Rule with Comment Period (November 2, 2020)
  APMA submitted comments to CMS in response to its third COVID-19 Interim Final Rule with Comment Period.
• APMA Urges CMS to Delay Recoupment from Medicare Accelerated and Advance Payment Program (August 17, 2020)
  APMA wrote to the CMS administrator urging the administration to delay recouping funds from physicians who took advantage of the Medicare Accelerated and Advance Payment Program, and APMA made several recommendations to ensure recoupment terms are less burdensome and onerous.
• APMA Joins AMA and Other Organizations in Urging HHS To Waive Budget Neutrality Requirements (July 1, 2020)
  APMA, along with the American Medical Association (AMA) and other organizations, sent a letter to the Department of Health and Human Services (HHS) urging HHS to preserve patient access to care and mitigate financial distress due to the pandemic by implementing the office visit increases as planned while waiving budget neutrality requirements for the new Medicare office visit payment policy.
• APMA Submits Comments to HHS Regarding the HHS Provider Relief Fund (June 4, 2020)
  APMA submitted comments to HHS requesting assistance for providers who were eligible and should have received funds via the first allocation ($30 billion) of the HHS Provider Relief Fund, but did not.
• APMA Submits Comments to DOD in Response to and in Support of Its Interim Final Rule with Comment Period on TRICARE Telehealth Services (May 25, 2020)
  APMA submitted comments supporting the Department of Defense's expansion coverage of audio-only telehealth services for TRICARE beneficiaries during the COVID-19 pandemic.
• APMA Submits Comments on Next Pandemic Relief Package (May 11, 2020)
  APMA submitted comments to US House and Senate Leadership regarding the myriad issues that APMA hopes to have addressed in the next relief package.
• APMA Submits Comments to SBA in Response to IFR on the PPP (April 27, 2020)
  APMA submitted comments to the Small Business Association in response to its Interim Final Rule on the Paycheck Protection Program (PPP).
• APMA Joins Coalition to Request that Congress Provide Increased Access to DSMT and MDPP (April 21, 2020) 
  DSMT is an evidence-based service that teaches people with diabetes how to effectively self-manage their diabetes and cope with the disease. The Medicare Diabetes Prevention Program (MDPP) allows Medicare reimbursement for CDC-recognized diabetes prevention programs for seniors at risk for type 2 diabetes. As Congress works on the fourth coronavirus relief package, APMA and other organizations join together to encourage the passage of legislation to relax requirements in these programs to allow for greater participation by providers and patients in the hope that these changes will result in keeping these patients out of hospitals during the pandemic.
• APMA Submits Comments to CMS in Response to Its Interim Final Rule with Comment Period on Telehealth Provisions (April 16, 2020)
  APMA submitted comments addressing Medicare and Medicaid telehealth provisions during the COVID-19 Public Health Emergency.
• APMA Advocates for Increased Relief for Members in Fourth Congressional Relief Package (April 13, 2020)
  APMA requested that Congress address hazard pay, PPE, testing and provider safety, aid for unemployed and underemployed providers, support for rural facilities, and increased access to telehealth services in the next COVID-19 relief package. 
• National Podiatric Organizations Urges Governors to Relax Scope-of-Practice Laws During Public Health Crisis (April 8, 2020)
  APMA, along with the American Board of Foot and Ankle Surgery, the American Board of Podiatric Medicine, the American College of Foot and Ankle Surgeons, and the American College of Podiatric Medicine, sent a letter to the National Governors Association urging governors to temporarily relax the scope of practice for DPMs during the COVID-19 health crisis. The APMA Board of Trustees approved a position statement supporting the loosening of scope-of-practice restrictions for podiatrists to allow them to assist in easing the burden.
• APMA Requests Clarification from Department of Homeland Security on Essential Workforce List (April 8,2020)
  APMA wrote to the Department of Homeland Security Workforce requesting clarification on the Advisory Memorandum on Identification of Essential Critical Infrastructure Workers During COVID-19 Response, issued March 28, 2020.
• APMA Advocates for Audio-Only Telehealth (April 3, 2020) 
  APMA and others request to expand Medicare coverage of telehealth to allow audio-only communications and waive the current Medicare requirement for audio-video connecting during the COVID-19 public health emergency. 
• APMA Urges Government To Secure PPE (April 3, 2020)
  APMA and more than 200 health-care organizations request that the government take immediate action to alleviate the critical shortage across the nation of ventilators and personal protective equipment (PPE), such as masks, face shields and gowns, resulting from the COVID-19 pandemic.
• APMA Urges Department of Labor to Exempt Podiatric Offices (March 26, 2020)
  APMA wrote to US Labor Secretary Eugene Scalia requesting that as he uses his authority under the Families First Coronavirus Response Act to exempt small businesses from providing child-care-related paid sick leave and expanded family and medical leave, he include podiatric offices and waive any applications and other criteria
• APMA Submits Comments to CMS in Response to and in Support of Changes to the 2019 MIPS Performance Year Reporting Requirements (March 26, 2020)
  In response to the ongoing COVID-19 crisis, CMS issued changes to the 2019 MIPS performance year reporting requirements by extending the reporting deadline and creating an automatic hardship exception for clinicians who did not report. APMA submitted comments to CMS in response and recommended not penalizing any clinicians who had already reported and scored below the performance threshold as well as recommending modifying the 2020 MIPS performance period generally.

Other Efforts

• APMA and its state components signed on to two coalition letters led by the American Academy of Dermatology along with more than 72 other medical societies asking America's Health Insurance Plans and Blue Cross Blue Shield Association to harmonize the disparate requirements its member companies have provided regarding telemedicine by asking them to align with CMS guidelines, reimburse telehealth at in-office rates, and mirror CMS guidance coding guidance for these services.
• APMA signed a coalition letter led by the American College of Physicians along with 40 other societies asking CMS to pay telephone E/M services at the same rate that office/outpatient E/M services pay and to ensure that the MACs are following guidance from CMS to pay telephone E/M services.

Members can find all COVID-19 CMS-related news on this page. For relevant COVID-19 related APMA resources, including APMA recommendations and access to financial resources during this public health emergency, visit www.apma.org/COVID19. 

Medicare

• General CMS COVID-19 Resource Page
• Suspension of Medicare Sequester Through December 31, 2021
  Section 3709 of the CARES Act temporarily lifts the Medicare sequester, which reduces payments to providers by 2 percent, from May 1 through December 31, 2020, boosting payments for hospital, physician, nursing home, home health, and other care. The Medicare sequester would be extended by one year beyond current law to provide immediate relief without worsening Medicare’s long-term financial outlook. The US Congress voted in March to extend these cuts until December 31, 2021. Read APMA's full CARES Act summary.
• CMS Advanced and Accelerated Payment Program (Suspended on April 26, 2020)
  CMS announced on April 26 its decision to reevaluate the amounts that will be paid under the Accelerated Payment Program and to suspend its Advance Payment Program to Part B suppliers. Find information about repayment and recoupment timelines and terms here.
• Provider Relief Fund
  On April 10, 2020, the Department of Health and Human Services (HHS) began distributing the initial $30 billion in relief funding to Medicare fee-for-service (FFS) facilities and providers. These are grants, not loans, and do not have to be repaid. The funds you will receive from this fund will be in direct proportion to your practice’s share of Medicare fee-for-service spending. Hypothetically, if a Medicare provider with a Taxpayer ID Number (TIN) accounted for 1 percent of total Medicare FFS spending in 2019, the TIN would receive 1 percent of the $30 billion. All facilities and health professionals that billed Medicare FFS in 2019 are eligible for the funds. In September 2021, HHS announced the availability of $25.5 Billion in COVID-19 Provider Funding  for Phase 4 which opened on September 29.
  
  If you have not yet received the funds directly in your bank account, check with the bank account associated with your practice’s TIN. The automatic payments will come to the organizations via Optum Bank with "HHSPAYMENT" as the payment description. Within 30 days, you must sign and submit an attestation confirming receipt of the funds and agreeing to the terms and conditions of payment. The portal for signing the attestation will be open the week of April 13 and will be linked from hhs.gov/providerrelief.
  
  APMA strongly encourages members to read the terms and conditions closely before attesting, and seek guidance from their legal counsel if necessary.
• Expansion of Covered Telehealth Services in Response to COVID-19
  Please visit APMA’s full resource page on updates to providing non-face-to-face services.
  The OCR has also issued additional guidance on relaxed enforcement discretion for telehealth remote communications during the COVID-19 public health emergency:
    - OCR Bulletin: 2020 HIPAA and Novel Coronavirus (PDF, February 2020)
• Provider Enrollment Relief Information
  The March 22 FAQ includes toll-free hotlines available to provide expedited enrollment and answer questions about COVID-19 enrollment requirements. As noted in the FAQs (updated August 2021), CMS is exercising its 1135 waiver authority in the following ways:

Physicians and Non-Physician Practitioners

Establish toll-free hotlines to enroll and receive temporary Medicare billing privileges Waive the following screening requirements: Criminal background checks associated with fingerprint-based criminal background checks (FCBC)—42 C.F.R 424.518 (to the extent applicable) Site visits—42 C.F.R 424.517 Postpone all revalidation actions

All Other Providers and Suppliers (including DMEPOS)

Expedite any pending or new applications All clean web applications will be processed within seven business days and all clean paper applications in 14 business days Waive the following screening requirements for all enrollment applications received on or after March 1, 2020: Criminal background checks associated with the FCBC – 42 C.F.R. 424.518 (to the extent applicable) Site-visits – 42 C.F.R. 424.517 Postpone all revalidation actions

Additionally, the FAQ addresses the process for physician and non-physician practitioners to initiate temporary Medicare billing privileges, including through an enrollment hotline, licensure, revalidation, and more.

• Changes for 2021 MIPS PY Reporting
  CMS has made available again the COVID-19 Extreme & Uncontrollable Circumstances (EUC) Exception. Providers must proactively submit their application for this exception by December 31, 2021. Providers may apply to reweight one to all of the performance categories to zero, for a neutral payment adjustment to the 2023 payment year. Applications for this EUC will need to include a brief description of the data collection challenges you faced as a result of COVID-19 and how your 2021 performance will be impacted (although there is still no formal documentation requirement). Follow APMA's step-by-step instructions when applying for a 2021 MIPS PY COVID-19 EUC. Additional information can be found at www.apma.org/MIPS2021.

Medicaid

• General CMS Medicaid COVID-19 Resource Page
• Medicaid Telehealth
  Please visit APMA’s full resource page on updates to providing non-face-to-face services.
• States Currently Approved for 1135 Medicaid Waivers
  CMS has approved 1135 Medicaid Waivers, offering all states and the District of Columbia new flexibility to focus their resources on combating the outbreak and providing the best possible care to their Medicaid beneficiaries.

Alabama	Illinois	Montana	Rhode Island
Alaska	Indiana	Nebraska	South Carolina
Arizona	Iowa	Nevada	South Dakota
Arkansas	Kansas	New Hampshire	Tennessee
California	Kentucky	New Jersey	Texas
Colorado	Louisiana	New Mexico	Utah
Connecticut	Maine	New York	Virginia
Delaware	Maryland	North Carolina	Vermont
District of Columbia	Massachusetts	North Dakota	Washington
Florida	Michigan	Oklahoma	West Virginia
Georgia	Minnesota	Ohio	Wisconsin
Hawaii	Mississippi	Oregon	Wyoming
Idaho	Missouri	Pennsylvania

Page last updated September 29, 2021.

Looking for information on past rounds of Provider Relief Funds?

4th Round of Provider Relief Funds - Application Opens on September 29, 2021, Closes on October 26, 2021

On September 29, the Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), will start accepting applications for Phase 4 of the Provider Relief Fund (PRF).

Included in this round is $25.5 billion in new funding for providers affected by the COVID-19 pandemic, specifically those who serve rural Medicaid, Children’s Health Insurance Program (CHIP), or Medicare patients, in addition to providers who are able to document revenue loss and increased operating expenses associated with the pandemic. Lost revenue and expenses will be calculated from the period of July 1, 2020, to March 31, 2021. To see if you qualify for areas deemed “rural,” view the Rural Health Grants Eligibility Analyzer on the HHS website. 

To prepare for this round, you will need a copy of your most recent tax returns as well as financial statements from the second half of calendar year (CY) 2020 and the first quarter of CY 2021. Providers must submit their completed application by the final deadline of October 26 at 11:59 p.m. ET. Providers who have previously created an account in the Provider Relief Fund Application and Attestation Portal and have not logged in for more than 90 days will need to first reset their password before starting a new application.

Provider Relief Funds Reporting Requirements

Providers that received aggregated Provider Relief Fund (PRF) payments in excess of $10,000 in a single reporting period are required to report using the PRF Reporting Tool. Reporting is required if a provider received General or Targeted Distributions. The following table summarizes reporting requirements for payments received during each Payments Received Period. On June 11, 2021, HHS released revised reporting requirements for recipients of PRF payments, which maintained the lowered the threshold from the August 14, 2020 Notice – from $150,000 in the Terms and Conditions to $10,000. These forms provide complete, detailed information on provider reporting guidelines, including intent, use of funds, and data elements requested. The PRF Reporting Portal opened for providers to start submitting information on July 1, 2021, with the first round of reporting due on September 30, 2021. Note that HHS has extended this deadline to November 30 as a grace period, and providers who do not report by September 30 will still be considered out of compliance. However, no collection activities or similar enforcement actions will be initiated during this 60-day grace period. Providers who are able to complete their report by September 30 are strongly encouraged to do so.

APMA has worked with Hart Health Strategies to create a webinar for members to assist in navigating reporting, as well as a detailed summary. 

Podiatrists who have gone through the reporting process recommend accessing the following documents and information prior to reporting:

1. Any interest earned on the PRF payments
2. Other sources of assistance received (e.g., SBA, FEMA, business insurance, local and tribal government assistance)
3. PRF expenses totals for general and administrative expenses, as well as health-care-related expenses from Q1 2020 through Q2 2021
4. Total revenues from 2019 and 2020
5. Number of part-time, full-time, and contractor clinical and non-clinical employees from Q1 2019 through Q2 2021
6. Number of furloughed, separated, and hired part-time, full-time, and contractor clinical and non-clinical employees from Q1 2019 thru Q2 2021
7. Number of patient visits from Q1 2019 thru Q2 2021

Additional Key Dates

	Payment Received Period (Payments Exceeding $10,000 in Aggregate Received)	Deadline to Use Funds	Reporting Time Period
Period 1	From April 10, 2020 to June 30, 2020	June 30, 2021	July 1 to September 30, 2021*
Period 2	From July 1, 2020 to December 31, 2020	December 31, 2021	January 1 to March 31, 2022
Period 3	From January 1, 2021 to June 30, 2021	June 30, 2022	July 1 to September 30, 2022
Period 4	From July 1, 2021 to December 31, 2021	December 31, 2022	January 1 to March 31, 2023

* Please note, HHS has extended this deadline to November 30 as a grace period, and providers who do not report by September 30 will still be considered out of compliance. However, no collection activities or similar enforcement actions will be initiated during this 60-day grace period.

Terms and Conditions

Recipients of Provider Relief Fund payments must agree to the Terms and Conditions specific to the distribution in which they received a payment or reimbursement.

Providers must attest to program Terms and Conditions in order to receive payment, such as:

• Eligible providers may use funds to prevent, prepare for, and respond to coronavirus, and for related expenses or lost revenues attributable to coronavirus.
• Funding cannot be used where another source has reimbursed or is obligated to reimburse those expenses or losses.
• Payments can be pre-payments, prospective, or retrospective payments.
• Provider and payment information for entities that have attested to at least one payment is posted to an HHS Public Use File (PUF)

General Distribution

• Phase 1
  - Relief Fund Payment from $30 Billion General Distribution: The recipient automatically received payment from the initial $30 billion general distribution.
  - Relief Fund Payment $20 Billion General Distribution: The recipient has received payment from the additional $20 billion general distribution.
• Phase 2
  - Phase 2 General Distribution Relief Fund Payment Terms and Conditions: The recipients have received a payment appropriated as part of Phase 2 General Distribution, including Medicaid, CHIP, dental, and other providers.
• Phase 3
  - Phase 3 General Distribution Relief Fund Terms and Conditions: The recipients have received a payment appropriated as part of Phase 3 General Distribution, including Medicaid, CHIP, dental, assisted living facilities, behavioral health and other providers.

Targeted Distribution

• COVID-19 High-Impact Payments
  High Impact Area Relief Fund Payment Terms and Conditions: The recipient has received payment from funds appropriated as part of the targeted allocations known as the High Impact Area Targeted Distribution.

Rural Payments

• Rural Targeted Distribution: The recipient has received payment from funds appropriated as part of the targeted allocations known as the Rural Targeted Distribution.

In reviewing the terms and conditions, there are a few key items for providers to consider, as detailed below.

Possible or actual cases. Providers must attest that they “[provide] or provided after January 31, 2020, diagnoses, testing, or care for individuals with possible or actual cases of COVID-19.” The initial terms and conditions did not include the specific date. While this information is not included in the terms and conditions, HHS on its website further noted that “HHS broadly views every patient as a possible case of COVID-19.” With the addition of the date and the HHS clarification, providers may be able to attest to this requirement if they treated any patient after January 31, whether via telehealth or in person.

Reallocating funds. At this time, there is a not a process to allow an entity to reallocate the funds to different a TIN in light of changes in ownership or new providers. This situation is a particular issue given that the legacy TINs may not be able to attest to the ability to treat patients and, as such, may have difficulty in attesting to retain the funds.

Bans balanced billing. In essence, to retain the funds, a provider must not balance bill for “all care for a presumptive or actual case of COVID-19.” For those patients, the provider must not seek from the patient more than the patient would have been obligated to pay if the provider was an in-network provider. While it is still unclear which cases would be “presumptive or actual” cases, one could attest that this subset of patients is different from “possible or actual” (which is essentially all patients) but would still apply to all patients in that subset, regardless of payer. And, given that this language does not have a similar date qualifier (i.e., the January 31 date), it is unclear when HHS expects the balance billing requirement to be in effect. This situation is particularly troubling, given that, so far, there has been no discussion regarding the amount of payment required.

Note that the secretary has concluded that the COVID-19 public health emergency has caused many health-care providers to have capacity constraints. As a result, patients who would ordinarily be able to choose to receive all care from in-network health-care providers may no longer be able to receive such care in-network. Accordingly, for all care for a presumptive or actual case of COVID-19, the recipient certifies that it will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network recipient.

No other reimbursement. One additional requirement is that the “recipient certifies that it will not use the payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.” Unfortunately, HHS did not provide enough information for providers to easily untangle how to provide appropriate accounting for these items, especially given that many health-care services may be under additional obligations (e.g., Medicare payment for certain telehealth services), interactions with other government programs (e.g., the Paycheck Protection Program), etc.

Salary cap. The funds provided cannot be used to “pay the salary of an individual, through a grant or other extramural mechanism, at a rate in excess of Executive Level II.” According to OPM, Executive Level II is $197,300 for 2020. On its website, HHS has stated that “these are payments, not loans” but has not clarified whether this is an “extramural mechanism” subject to this restriction.

Use of funds. Another key requirement is that the “recipient certifies that the payment will only be used to prevent, prepare for, and respond to coronavirus, and shall reimburse the recipient only for health-care related expenses or lost revenues that are attributable to coronavirus.” This requirement is confusing at best, and it seems virtually impossible to use the fund at the same time for both care and lost revenue. Therefore, additional clarity is needed, especially in light of the extensive reporting requirements for the program.

Not an exhaustive list. The terms and conditions include a statement that “[t]his is not an exhaustive list and you must comply with any other relevant statutes and regulations, as applicable.” Further, the notice states that “[n]on-compliance with any term or condition is grounds for the secretary to recoup some or all of the payment made from the Relief Fund.”

Subcontractors. Another key statement is that “[t]hese terms and conditions apply directly to the recipient of payment from the Relief Fund. In general, the requirements that apply to the recipient, also apply to subrecipients and contractors, unless an exception is specified.”

Additional language from $20 billion allocation. The additional language in the terms and conditions for the second tranche (e.g., $20 billion allocation) is as follows: “The recipient shall also submit general revenue data for calendar year 2018 to the secretary when applying to receive a payment, or within 30 days of having received a payment. The recipient consents to the Department of Health and Human Services publicly disclosing the payment that recipient may receive from the Relief Fund. The recipient acknowledges that such disclosure may allow some third parties to estimate the recipient’s gross receipts or sales, program service revenue, or other equivalent information.”

Additional Resources

• Health Resources & Services Administration (HRSA)
  Three documents are now available to assist with reporting:
  • Lost Revenues Guide
  • Allowable Personnel Expenses
  • Reporting Resource Guide
  • HHS General Distribution FAQ

• Foley & Lardner Webinar: COVID-19 Provider Relief Funding - Use of Funds, Attestations, and Risk Analysis

APMA is providing resources to assist members with running their offices in a safe manner for their patients and staff during the public health emergency. 

Jump to Section
Risk Management Resources and Checklists
Employee Issues
Elective Procedures and Non-Emergent Non-COVID-19 Health Care
State-by-State Issues
Additional Resources 

Risk Management Resources and Checklists

• PICA Reopening Checklist
• ProAssurance Returning to Practice Guide

Employee Issues

• OSHA Emergency Temporary Standards for Healthcare Settings
• OSHA Guidance on Preparing Workplaces for COVID-19
• EPA Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes
• EEOC Guidance on Pandemic Preparedness in the Workplace and Other Resources for Employers

Elective Procedures and Non-Emergent Non-COVID-19 Health Care

• CMS Recommendations for Re-Opening Facilities to Provide Non-emergent Non-COVID-19 Health Care: Phase I
• CMS Recommendations for Re-Opening Facilities to Provide Non-emergent Non-COVID-19 Health Care: Phase II
• Joint Statement: Roadmap for Resuming Elective Surgery after COVID-19 Pandemic
• AAOS Guidance for Elective Surgery
• American College of Surgeons’ Local Resumption of Elective Surgery Guidance

State-by-State Resources

• National Governors Association State Action Tracker
• 50-State Emergency Order Tracker: Roadmap to Restart

Additional Resources

• Hart Health Strategies Opening Practice Guide
• White House COVID-19 Action Plan
• Soft Skills in Health-Care Management

While these resources provide background information and practice solutions for podiatric physicians, APMA is not rendering legal or other professional advice. APMA encourages readers of these resources who need assistance to consult with an attorney duly licensed in your jurisdiction.

The CDC and CMS have information, recommendations, and guidance for nursing homes and long-term care facilities. If you provide care at nursing homes or long-term care facilities, check out these resources.

General Information

The CDC provides general information on Nursing Homes and Long-Term Care Facilities as it relates to COVID-19.

CMS has created the Nursing Home Resource Center where you can find nursing home resources including COVID-19 public health emergency response information and a series of short podcasts for front-line nursing home staff.

Response to Infection

The CDC provides Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes including guidance related to how to handle a New Infection in Healthcare Personnel (HCP) or Resident.

Safe Visiting Practices 

CMS provides recommendations relating to Nursing Home Visitation – COVID-19, including visiting providers. Be sure to check with individual facilities you visit for any updated guidance.

Testing

The CDC’s Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes includes information on testing healthcare personnel and evaluating and managing health-care personnel. 

Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic describes recommendations regarding: 1) source control and physical distancing for fully vaccinated HCP; 2) universal use of PPE for HCP; and 3) testing.

CMS provides recommendations for state and local officials regarding nursing home reopening including access to adequate testing. CMS also has guidance for facilities to meet requirements related to testing residents and staff, including individuals providing services under arrangement and volunteers.

Vaccines

The CDC has Information About COVID-19 Vaccines for Long-term Care Facility Residents and Family Members available so you can help protect yourself and the people around you.

On May 11, 2021, CMS posted an Interim Final Rule - COVID-19 Long-Term Care Facility Vaccine Immunization Requirements for Residents and Staff. 

APMA, the CDC, and CMS provide information, recommendations, and guidance regarding the COVID-19 vaccination.

Become a Vaccinator

Biden Administration Vaccine Mandate Regulations

The administration has just released two rules related to mandatory vaccination against COVID-19. These include:

1. CMS Omnibus COVID-19 Health Care Staff Vaccination Interim Final Rule with Comment Period
   This interim final rule with comment period revises the requirements that most Medicare- and Medicaid-certified providers and suppliers must meet to participate in the Medicare and Medicaid programs. CMS states that changes are necessary to help protect the health and safety of residents, clients, patients, PACE participants, and staff, and reflect lessons learned to date as a result of the COVID-19 public health emergency. The revisions to the requirements establish COVID-19 vaccination requirements for staff at the included Medicare- and Medicaid- certified providers and suppliers.
   • Press Release
   • CMS Webinar: Omnibus COVID-19 Health Care Staff Vaccination (slide deck; PDF)
   • Frequently Asked Questions
     
     We encourage members to review all FAQs thoroughly, but APMA notes two relevant questions:
     
     Q: To which provider and supplier types does this apply?
     A: The staff vaccination requirement applies to the following Medicare and Medicaid-certified provider and supplier types: Ambulatory Surgery Centers, Community Mental Health Centers, Comprehensive Outpatient Rehabilitation Facilities, Critical Access Hospitals, End-Stage Renal 2 Disease Facilities, Home Health Agencies, Home Infusion Therapy Suppliers, Hospices, Hospitals, Intermediate Care Facilities for Individuals with Intellectual Disabilities, Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services, Psychiatric Residential Treatment Facilities (PRTFs) Programs for All-Inclusive Care for the Elderly Organizations (PACE), Rural Health Clinics/Federally Qualified Health Centers, and Long Term Care facilities.
     
     Q: Would a physician with admitting privileges in a hospital be covered under this requirement?
     A: Yes, a physician admitting and/or treating patients in-person within a facility subject to the CMS health and safety regulations and included as a part of this requirement must be vaccinated so that the facility is compliant.
     
     Q: Is a physician who acts as a physician DME supplier in their private practice considered a covered facility (and therefore all staff as well) under this requirement?
     No. But these employees may still be covered under OSHA's rules issued in June and this November.
     
     Q: Are there any exemptions for this mandate?
     CMS requires facilities to allow for exemptions to staff with recognized medical conditions for which vaccines are contraindicated (as a reasonable accommodation under the Americans with Disabilities Act (ADA)) or religious beliefs, observances, or practices (established under Title VII of the Civil Rights Act of 1964). Providers and suppliers should establish exceptions as a part of its policies and procedures and in alignment with Federal law. CMS believes that exemptions could be appropriate in certain limited circumstances, but no exemption should be provided to any staff for whom it is not legally required (under the ADA or Title VII of the Civil Rights Act of 1964) or who requests an exemption solely to evade vaccination.
     
     
2. OSHA Emergency Temporary Standard for COVID-19 Vaccination and Testing
   The Occupational Safety and Health Administration (OSHA) is issuing an emergency temporary standard (ETS) with the goal of protecting unvaccinated employees of large employers (100 or more employees) from the risk of contracting COVID-19 by strongly encouraging vaccination. Covered employers must develop, implement, and enforce a mandatory COVID-19 vaccination policy, with an exception for employers that instead adopt a policy requiring employees to either get vaccinated or elect to undergo regular COVID-19 testing and wear a face covering at work in lieu of vaccination.
   
   Physician offices with 100 staff or more generally are not subject to OSHA’s Vaccine and Testing ETS issued in November 2021 because physician offices must comply with OSHA’s Healthcare ETS that was issued in June 2021.  While OSHA’s Healthcare ETS did not include a vaccine mandate, it did require health-care settings, including physician offices, to implement effective COVID-19 plans to protect healthcare workers from COVID-19. However, certain employees may be exempt from OSHA’s Healthcare ETS, and those employees may be subject to OSHA’S COVID-19 Vaccination and Testing ETS. Because requirements are fact specific, APMA encourages physician offices, especially those with over 100 staff, work with a duly licensed attorney to ensure they comply with Federal requirements appropriately.
   
   Additionally as of November 15, 2021, the Fifth US Circuit Court of Appeals granted an emergency stay of OSHA’s Vaccinate and Testing ETS and declined Friday to lift its stay following the administration’s response. APMA is following developments related to this ETS closely.
   
   
   • About the ETS
   • ETS Summary

APMA is in the process of reviewing both rules and will provide members with more information in the coming days. Watch the APMA Weekly Focus for more news. Contact the APMA Health Policy and Practice Department if you have any questions in the meantime.

Vaccines and Masks

The Biden Administration announced on September 9, 2021, that it “will require COVID-19 vaccination of staff within all Medicare and Medicaid-certified facilities.” The administration also stated that this requirement would apply to “clinical staff, individuals providing services under arrangements, volunteers, and staff who are not involved in direct patient, resident, or client care.” An interim final rule with more details is expected to be issued in October.  

Additionally, as a separate component of President Biden’s COVID-19 Action Plan, the Department of Labor through the Occupational Safety and Health Administration (OSHA) has been tasked with issuing an Emergency Temporary Standard (ETS) to implement a requirement that all employers with 100 or more employees ensure that their workforce is fully vaccinated or that unvaccinated workers produce a negative test result on at least a weekly basis. As such, clinical practices with 100 or more employees will likely be subject to this requirement. The OSHA ETS is expected to be released in October. Absent more details, already, key questions about the proposal include who would pay for the COVID-19 testing, how employers would verify workers' vaccination status, and the proposal's intersection with religious exemptions. 

Members have asked APMA about mask requirements and face coverings in podiatric offices in light of recent (May 16, 2021; updated September 16, 2021) CDC guidance for those fully vaccinated. APMA recommends that podiatric offices comply with state or local jurisdiction rules regarding face-covering requirements as they apply to businesses and health-care settings.  

You should encourage your unvaccinated patients to follow recommendations on How to Protect Yourself and Others. APMA also recommends that podiatric physicians encourage eligible patients to get vaccinated and receive booster shots, as appropriate. 

Additional Guidance for Daily Activities; Guidance for Activities, Gatherings, and Holidays; and, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic are available from the CDC.  

APMA is not providing legal advice and encourages members to speak with a duly licensed attorney in their jurisdiction. 

Advocacy and Policy Positions

To support members and podiatric offices, APMA has engaged state and federal policymakers on the administration of vaccinations and following are recent examples of successful efforts: 

• Update: APMA Advocates for Podiatrists in Plans for COVID-19 Vaccine Distribution 
• APMA Advocates for DPMs on HHS COVID-19 Vaccinator Expansion Listening Session 
• APMA has advocated that DPMs be included in the first group (health-care workers) prioritized for the COVID-19 vaccine. 
• APMA also requested that residency directors advocate for podiatric medical students rotating in clinical experiences to receive the COVID-19 vaccination. 

APMA’s House of Delegates has adopted the following policy propositions regarding vaccinations: 

Policy Proposition 2-21: Podiatric Physician Routine Immunization 

APMA encourages doctors of podiatric medicine to be routinely immunized, especially when safe and effective vaccines are available, and especially for diseases that have potential to become epidemic or pandemic (e.g., influenza or SARS-CoV-2). Vaccines are essential for protecting individuals and communities from vaccine-preventable diseases and outbreaks. Vaccine-preventable diseases can be a threat to our health and vaccines can provide population-wide protection against disease. Notwithstanding, APMA recognizes and respects that some doctors of podiatric medicine may be unable to take certain vaccinations for medical reasons or because of firmly held religious beliefs, and APMA encourages such individuals to take appropriate precautions in effort to avoid spreading communicable diseases. 

Policy Proposition 3-21: Podiatric Physicians Administering Vaccines  

APMA supports including podiatric physicians, and podiatric residents, and podiatric medical students in the pool of professionals who can administer vaccines, especially when called upon in times of need for a disease that has potential to become epidemic or pandemic (i.e., influenza or SARS-CoV-2). Podiatric physicians and surgeons undergo education and training like their allopathic and osteopathic physician colleagues and possess more than enough experience to administer vaccines. Doctors of podiatric medicine are licensed, independent practitioners, and as such, APMA urges federal, state, and local governments to authorize podiatric physicians and podiatric residents to administer vaccines without any supervision requirements. 

General Vaccine Information

APMA's regulatory consultant, Hart Health Strategies Inc., has prepared a COVID resource document on the topic of COVID vaccines. 

The CDC provides a printable COVID-19 resource you can display in your office or provide to your patients. 

Information on the different COVID-19 vaccines, including information on vaccines in clinical trials, is available from the CDC.  

The CDC provides information on Who Is Eligible for a COVID-19 Vaccine Booster Shot and the We Can Do This campaign has infographics and social media content you can share.

The New England Journal of Medicine (NEJM) has a COVID-19 Vaccine Resource Center, which features a collection of resources on COVID-19 vaccines, including frequently asked questions, continuing medical education, published research, and commentary.  

Vaccine Administration 

CMS provides information related to COVID-19 vaccine administration to ensure the vaccine is covered and available free of charge for every American. CMS also has a tool kit regarding vaccine administration specifically for health-care providers. 

Clinical resources from the CDC are available for administration, storage and handling, patient education, and more for COVID-19 vaccine. 

The CDC has information for preparing your practice for COVID-19 vaccination. 

CMS has published information about the COVID-19 vaccine payment rate, vaccine coding guidance, and how to bill for COVID-19 shot administration.  

If you participate in the CDC COVID-19 Vaccination Program, you must: 

• Administer the vaccine with no out-of-pocket cost to your patients for the vaccine or administration of the vaccine 
• Vaccinate everyone, including the uninsured, regardless of coverage or network status 

You also can't: 

• Balance bill for COVID-19 vaccinations 
• Charge your patients for an office visit or other fee if COVID-19 vaccination is the only medical service given 
• Require additional medical or other services during the visit as a condition for getting a COVID-19 vaccination 

FAQ

Q: Can podiatrists prescribe and/or administer vaccines for COVID-19?

On March 11, HHS made an amendment to the Public Readiness and Emergency Preparedness (PREP) Act Declaration to allow more qualified professionals to prescribe, dispense, and administer COVID-19 vaccinations, including podiatrists, recently retired podiatrists, and podiatric medical students. HHS has determined that the PREP Act clearly preempts state law. Therefore, regardless of scope of practice restrictions, DPMs, retired DPMs, and students may serve as vaccinators so long as they meet certain conditions. Ultimately, states and territories may choose which qualified persons to use for vaccinations in their jurisdiction. Read more: Biden Administration Authorizes DPMs, Students to Administer COVID-19 Vaccine.

Become a Vaccinator

Several states have already authorized podiatrists to administer vaccines, and as of April 1, 2021, APMA is aware of nine states that have taken action:

• California
• Colorado
• Connecticut
• Florida
• Illinois
• Massachusetts (3/25/21 Update and Board of Podiatry Statement)  
• Minnesota
• Nevada
• New Mexico (Contact the Department of Health or Board of Podiatry)
• New York

State requirements that do not effectively prohibit qualified persons, such as additional training, are not preempted by the PREP Act. You will need to contact the state department of health for more information or to ask questions.

APMA encourages members to contact their state health department or licensing board for more information. 

The CDC has materials for preparing your practice for COVID-19 vaccination, including the CDC's Vaccine Training Modules and a printable "Facts about COVID-19 Vaccines" resource you can provide to your patients.

Q: Can podiatrists require their office staff to receive the COVID-19 vaccination?

Generally, you can require your employees to get vaccinated if by not getting the vaccine they pose a direct threat to customers or other employees. In the context of a physician's office, it is probably easy to demonstrate that employees would pose a direct threat to patients if the employee was not vaccinated.   

However, any policy that requires employees to receive the COVID-19 vaccine must comply with the Americans with Disabilities Act, Title VII of the Civil Rights Act of 1964, and other workplace laws. The Equal Employment Opportunity Commission has provided guidance to employees in Section K of What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws. 

Note: See Sections K.5, K.6, and K.7 on when employers must provide a disability or religious exemption or a reasonable accommodation to employees.

More information is also available from the Society for Human Resource Management regarding what employers can do if workers refuse a COVID-19 vaccination and when employers can require COVID-19 vaccinations.

Lesions and other dermatologic manifestations have been observed as a potential symptom of COVID-19. These lesions can appear in several places, including the feet. The "COVID Toes" phenomenon requires further study.

AAD COVID-19 Registry

In 2020, APMA worked closely with the American Academy of Dermatology (AAD) on its established COVID-19 registry, www.aad.org/covidregistry. Listen to this message from then-APMA President Seth Rubenstein, DPM, about the value of your participation.

APMA encourages its members to report cases of lesions on the feet associated with COVID-19 through this registry because it could have immediate and long-term strategic benefits for our profession.

“The emergence of so-called 'COVID Toes' is an opportunity for our profession to both contribute meaningful data as well as assist with research, publish papers, and collaborate with another medical specialty in education and research opportunities. Developing peer-to-peer relationships with the house of medicine can also open other doors for advocacy and education,” then-APMA President Seth Rubenstein, DPM, said. The principal investigator of the AAD Registry, Esther Freeman, MD, PhD, shared that, “We have seen a broad range of cutaneous manifestations in COVID-19, many of which involve the extremities and acral surfaces. We look forward to collaborating with our colleagues from APMA.”

The AAD COVID Registry is HIPAA-compliant and Institutional Review Board (IRB)-approved.

Webinar

In early 2020, Tracey Vlahovic, DPM, reviewed dermatologic manifestations of viral diseases, including those associated with COVID-19. You can watch Dr. Vlahovic below as she discusses scientific literature related to dermatologic manifestations and how they are related to podiatric medicine. 

Download a PDF of the presentation.

Academic Sources

"COVID-19 and Dermatology: One Year in Review"
Editorial, Dermatol Clin, October 2021. Esther Freeman, PhD, and Devon McMahon, MD

"The spectrum of COVID-19-associated dermatologic manifestations: An international registry of 716 patients from 31 countries"
J Am Acad Dermatol, October 2020. Freeman E, et al.

"Foot Manifestations in a COVID-19 Positive Patient: A Case Study"
Clinical Correspondence, JAPMA, May 4, 2020. Michael Nirenberg, DPM, and Maria del Mar Ruiz Herrera

"Addressing the Question of Dermatologic Manifestations of SARS-CoV-2 Infection in the Lower Extremities: A Closer Look at the Available Data and its Implications"
Letter to the Editor, JAPMA, April 20, 2020. Rami Basatneh, DPM, and Tracey Vlahovic, DPM

Recommended Resources

What to Do if Staff Test Positive

CDC/WHO Guidance for Health-Care Professionals

• FAQ for Health-care Professionals 
• Information for Health-care Professionals
• Information for Health-care Facilities
• Infection Control Guidance
• Guidance for Health-care Personnel with Potential Exposure
• Infection Prevention and Control Recommendations Webinar
• Information for Long-term Care Facilities, Nursing Homes
• WHO Overview
• WHO Advice for Health-Care Workers
• Rolling Updates

Recommendations for Clinical Practice 

• Wound Center without Walls: The New Model of Providing Care during the COVID-19 Pandemic, WOUNDS

Practice, Legal, and Financial Resources

• PICA’s COVID-19 Recommendations
• Printable Door Sign
• Sample Letter to Referring Physicians
• Department of Labor’s Employer Paid Leave Requirements and Employee Paid Leave Rights
• Information for Businesses and Employers from the CDC
• Foley & Lardner, LLP, Coronavirus Resource Page
• Fox Rothschild, LLP, Coronavirus Resources for Physicians and Dentists
• Federation of Podiatric Medical Boards State-by-State Resources
• OSHA Coronavirus Guidance
  
• Student Debt Information
• February 2021 Statement on Student Loans: Repayment Strategies and the CARES Act
• Sample Social Media Posts For Your Practice