State Medicaid Changes Can Improve Access to Coverage and Care During and After COVID-19 Crisis

Many states are taking advantage of Medicaid’s flexibility and emergency authorities to make it easier for people to qualify for and enroll in coverage and obtain affordable health care during the current public health crisis. More states should consider implementing these policies, especially as the pandemic continues and more people need Medicaid coverage. Fortunately, there’s still time. Health and Human Services (HHS) Secretary Alex Azar recently renewed the public health emergency (PHE) declaration through the end of October, enabling states to continue to leverage Medicaid’s emergency authorities to make temporary changes to their programs to improve access to coverage and care. Secretary Azar also has the authority to continue the PHE until the crisis is determined to have passed.

But even after the PHE ends, the need for improved access to coverage and care will continue. But even after the PHE ends, the need for improved access to coverage and care will continue. While some of the policies states have adopted respond to specific needs driven by the pandemic, most would help beneficiaries under any circumstances by making it easier to qualify for and enroll in Medicaid coverage as well as to access and afford care. These policy changes will be especially important if the COVID-19 recession — and resulting increased need for Medicaid coverage — continues beyond the PHE. Fortunately, states can make many of their temporary improvements permanent by filing traditional Medicaid state plan amendments (SPAs) or amendments to their verification plans. States should make these changes now to ensure there are no disruptions when implementing policies that make it easier for people to qualify for, enroll in, and obtain affordable health care.

Making It Easier to Qualify for Coverage

States are making it easier for people to qualify for Medicaid coverage by expanding coverage, giving people more time to meet certain eligibility criteria, and using less restrictive eligibility standards during the crisis. States can put these policies in place using a combination of Medicaid disaster SPAs and disaster relief eligibility verification plan changes. (See box, “Medicaid Pathways to Change Eligibility, Enrollment, and Coverage.”)

Expanding Coverage

Ensuring people have health insurance coverage is an important tool for fighting COVID-19. Without it, people with COVID-19 symptoms may be afraid to seek testing or treatment because they worry they can’t afford care. States have amended their Medicaid state plans to:

• Cover testing for the uninsured. The Families First Coronavirus Response Act (Families First) created a Medicaid state option to cover COVID-19 testing and testing-related services for uninsured individuals during the PHE, with the federal government paying 100 percent of the cost. While there is no income test for this optional eligibility group, people must be uninsured and meet Medicaid’s citizenship/immigration and state residency requirements.^[1] Eighteen states have elected this option under approved Medicaid disaster SPAs.^[2] (See Appendix Table 1.)

• Temporarily cover out-of-state and non-state residents. To qualify for Medicaid coverage, people generally must be residents of and living in the state in which they’re applying for coverage.^[3] But three states have elected to temporarily provide Medicaid coverage to individuals living in their states who are not residents. Alaska is electing to cover non-residents who are temporarily in the state and meet all other eligibility criteria, Washington is covering non-residents who are quarantined in Washington, and West Virginia is covering non-residents caring for a family member due to illness or quarantine.^[4]

  States can also continue coverage for people temporarily absent from the state in certain circumstances. Recognizing that some of their residents may have had to leave the state or are otherwise absent because of COVID-19, 12 states have approved Medicaid disaster SPAs that expand their definitions of temporary absence so that these individuals remain covered while temporarily out of state.^[5] (See Appendix Table 1.)

Extending Reasonable Opportunity Period

To verify Social Security numbers and citizenship or immigration status, states match applicant-provided information with Social Security Administration and Department of Homeland Security databases. Most applicants’ information can be verified through these sources, but some applicants must provide further information to complete the verification process.

In those cases, states must provide benefits and provide a “reasonable opportunity period” to allow the applicant or the Medicaid agency to resolve the discrepancy. The reasonable opportunity period must last at least 90 days from when the agency sends the client a notice, and it can be extended with continuation of benefits if the individual is making a good faith effort to obtain documents or the Medicaid agency needs more time. Seven states have approved Medicaid disaster SPAs extending the reasonable opportunity period beyond the initial 90-day period to resolve any discrepancies.^[6] (See Appendix Table 1.)

Using Less Restrictive Eligibility Criteria

Seniors and people with disabilities are more likely to become seriously ill from COVID-19, making their health coverage especially vital. Medicaid eligibility rules for seniors and people with disabilities are more complex than for other enrollees, but states have several options to simplify eligibility and enrollment processes for this group. For example, rather than requiring beneficiaries to submit bills showing that they meet their “spenddown,” states can disregard certain income above the eligibility threshold. California has elected to do this, disregarding all income up to 138 percent of the federal poverty line for seniors and people with disabilities, while Minnesota and Washington are disregarding unemployment income from their income methodologies.^[7] Or, states can increase their asset limits or fully eliminate their resource tests, as Illinois has elected to do, to simplify processing and reduce the need for extensive verification documents.^[8] States with resource tests can verify them through their Asset Verification Services (AVS) post-enrollment, and only require documentation if the AVS indicates resources above the resource limit.

Making It Easier to Enroll in Coverage

States have been leveraging emergency authorities to streamline the enrollment process to make it easier for people to enroll in coverage during the PHE, including by expanding the use of presumptive eligibility (PE), accepting self-attestation, verifying income and other eligibility factors after people are enrolled in coverage, and modifying standards for data compatibility.

Expanding Presumptive Eligibility

Presumptive eligibility allows hospitals, clinics, and other entities to screen individuals for Medicaid eligibility, and to temporarily enroll those who appear eligible. Individuals can then submit a full Medicaid application for ongoing coverage. In the current crisis, PE is a valuable option to quickly enroll people when they seek care, and because PE doesn’t require an applicant’s signature, health care providers and other entities can make PE determinations during a virtual or telephonic visit. States have amended their Medicaid state plans to expand PE by:

• Expanding the number and types of “qualified entities” that can conduct PE determinations. Medicaid regulations give states broad authority to designate health care providers, schools, WIC agencies, other community-based service providers, and even the Medicaid agency itself as qualified entities capable of determining PE. Illinois, Kansas, Kentucky, New Jersey, and Ohio have temporarily amended their Medicaid state plans to allow their Medicaid agencies to conduct PE, and Oregon has given authority to contracted community partner organizations.^[9] New Mexico has also temporarily modified its Medicaid state plan to include a more expansive list of qualified entities, allowing Medicaid providers, schools, tribes, and organizations and agencies that determine eligibility for Head Start, WIC, emergency and public housing, as well as correctional facilities, to conduct PE.^[10]
• Ensure that qualified entities can determine PE for all Medicaid eligibility groups. If states provide PE for children and pregnant women, they can allow qualified entities to determine PE for other groups, such as parents/caretaker relatives, newly eligible adults, and former foster care children. Illinois, Kansas, Nebraska, Ohio, and Oregon have done this through their Medicaid disaster SPAs, and California, New Hampshire, New Mexico, and Utah have extended PE to individuals these states are covering through the new uninsured option described above.^[11] Some states, such as California, Iowa, Kentucky, Massachusetts, New Jersey, Ohio, Washington, and Wisconsin are allowing hospitals to conduct PE for new eligibility categories, including seniors and people with disabilities.^[12]
• Expand the number of PE periods in a given year. Some states limit individuals to a single PE period in a year, potentially delaying coverage for some people. Expanding the number of PE periods to two per year, as California, Illinois, Kansas, Massachusetts, New Jersey, Oregon, Utah, and Washington have done, can help ensure that people, such as those who may have gained employer coverage during the year only to lose it because of the economic downturn, have timely access to care.^[13]
• Liberalize state rules for hospitals that perform PE. While states have the option to designate other qualified entities, they are required to give hospitals the option to perform PE. Participating hospitals must meet state standards as to the percentage of individuals approved for PE who submit full Medicaid applications and for the percentage who are determined eligible. States can temporarily relax their performance standards to encourage more hospitals to perform PE, as Kentucky, Ohio, and Washington have done.^[14]

Allowing Self-Attestation for Non-Financial Factors

States often require additional information or verification documents from applicants before they approve eligibility, which can be challenging for applicants during a crisis and can delay enrollment. To minimize paperwork during this time, states can accept the information the applicant enters on the application form — known as self-attestation — for most non-financial eligibility factors including age or date of birth, residency, and household composition. (See Table 1.) States then only need to follow up on these factors if they have information that is inconsistent with what the applicant reported.^[15] The District of Columbia, Illinois, and Ohio are modifying their verification plans to accept self-attestation for non-income eligibility factors, such as receipt of other coverage (DC, IL, and OH), residency (DC and IL), household composition (DC), age and date of birth (DC), former foster care status (OH), and incurred medical expenses (IL).^[16]

Conducting Post-Enrollment Verification

States can also determine eligibility based on the information on the application and conduct post-eligibility verification. After enrolling the applicant, the agency can compare the self-attested information to electronic data sources, and request verification if needed. This allows states to quickly enroll individuals in need of medical coverage and run the data checks and request verification documents (if necessary) after the individual has been enrolled.

Delaware, the District of Columbia, Indiana, Louisiana, Vermont, and Washington have modified their verification plans to conduct post-enrollment verification of income. Maine is also conducting post-enrollment verification of income, but in phases, with the first phase having started in May. States that choose not to accept self-attestation of eligibility factors, like residency and date of birth, can verify them after enrollment. For example, Indiana is verifying residency, age/date of birth, household composition, and receipt of other coverage after enrollment.^[17]

Increasing Reasonable Compatibility Standards

States are required to compare electronic data sources to income information provided by the applicant to determine whether the income provided by the applicant and the electronic data are “reasonably compatible.” If the information provided by the applicant and the electronic data are both below the eligibility threshold, they are reasonably compatible and no further verification is needed. In addition, states can establish a “reasonable compatibility standard,” which applies when the applicant’s attestation is below the eligibility threshold but data sources show income above the threshold. States may set an acceptable level of variance — either a percentage of income or a specific dollar amount — when the difference between the attestation and data sources doesn’t have to be reconciled by requesting additional information from applicants.^[18]

To date, three states have temporarily modified their reasonable compatibility standards using disaster relief verification plan addendums. Increasing the acceptable variance ensures that slight discrepancies around the eligibility threshold don’t prevent enrollment. Colorado increased its standard from 10 percent to 20 percent, Illinois from 5 percent to 30 percent, and Ohio from 5 percent to 15 percent.^[19]

Making It Easier to Access and Afford Care

In addition to making it easier to qualify for and enroll in coverage, states are ensuring people can access affordable care safely during the pandemic by expanding the use of telehealth and eliminating financial barriers that may limit needed care.

Expanding Telehealth

Telehealth is a great option for people to safely access health care during the pandemic as it allows people to seek needed medical care while avoiding any risk of infection. States have considerable flexibility when expanding the use of telehealth in their Medicaid programs. Under Medicaid, telehealth isn’t a service but rather a service delivery method, which means that states can expand its use without even having to submit an SPA. States are only required to submit an SPA if they intend to pay for services delivered via telehealth differently than services provided face-to-face. Additional SPAs may be needed if a state has previously included telehealth limitations in its Medicaid state plan, such as only allowing certain services to be delivered via telehealth, and would like to remove them.^[20] For example, states are using temporary Medicaid disaster SPAs to:

• Expand provision of services. The District of Columbia, Minnesota, and Nebraska are expanding the number of services allowed to be provided via telehealth, with Colorado, Connecticut, Kentucky, New Jersey, and Washington going even further and allowing all services to be provided via telehealth.^[21]
• Expand modalities. Delaware, Georgia, Maryland, Minnesota, Mississippi, and Ohio are expanding telehealth modalities, including telephonic delivery of services or assessments.^[22]
• Change payment. Illinois, Minnesota, Nebraska, North Carolina, and West Virginia are changing payment rates and methodologies, including for Federally Qualified Health Centers, Rural Health Centers, and tribal facilities.^[23]
• Expand provider participation. Several states, such as Minnesota and Missouri, are allowing more types of providers to furnish services via telehealth, and Colorado is even allowing licensed, out-of-state providers to furnish services to its Medicaid beneficiaries.^[24]
• Suspend certain requirements. California, Louisiana, Minnesota, and South Dakota are making it easier for services to be provided via telehealth by temporarily suspending certain requirements in their Medicaid state plans, such as face-to-face first visit requirements.^[25]

Eliminating Copayments

Although Medicaid law allows states to impose nominal copayments for certain services, research shows that cost sharing has negative effects on individuals’ ability to access needed care, worsens health outcomes, and increases financial burdens for families. In fact, research has found that “even relatively small levels of [Medicaid] cost sharing in the range of $1 to $5 are associated with reduced use of care, including necessary services. . . .”^[26]

To ensure that people seek needed medical care during the pandemic, 11 states have approved SPAs to temporarily suspend cost sharing for all services, not just on COVID-19 testing, through the end of PHE, with West Virginia suspending cost sharing for all services except for prescription drugs.^[27] Massachusetts and Vermont are suspending copayments on acute inpatient hospital stays and outpatient hospital visits, respectively.^[28] (See Appendix Table 1.)

Eliminating Premiums

Premiums are generally not permitted under Medicaid state plan authority except for certain groups, such as individuals with incomes above 150 percent of the federal poverty line and employed individuals with disabilities. As with other forms of cost sharing, extensive research shows that premiums serve as a barrier to maintaining and keeping coverage and lead to greater unmet health needs and financial burdens.^[29] To ensure access to care during this crucial time, 17 states are temporarily eliminating premiums in their Medicaid state plans for certain adult coverage groups and people with disabilities.^[30] (See Appendix Table 1.)

States Still Have Time to Do More

With the extension of the PHE, states still have time to respond to COVID-19 by making temporary changes to their Medicaid programs to improve access to affordable coverage.^[31] While progress has been made in making it easier to qualify for and to enroll in coverage as well as to access care, states can do more to help ensure people have affordable coverage during this crucial time, especially in streamlining eligibility and enrollment processes.

For example, as detailed above, to date, only 11 states have completed CMS’ eligibility verification plan disaster addendum templates for approval. These disaster addendums allow states to easily — and temporarily — make eligibility and enrollment changes, such as allowing self-attestation of income and non-income eligibility factors, and conducting post-enrollment verification. And while 45 states have approved Medicaid disaster SPAs, only a handful of states have implemented expanded PE, implemented less restrictive eligibility criteria, or extended reasonable opportunity periods.

CMS has made it easy for states to consider and elect various eligibility, enrollment, and coverage changes to respond the pandemic by creating Medicaid disaster SPA templates and verification plan addendums. These templates allow states to simply “check the box” of the policy they’d like to change, and for how long. States can implement these changes through the end of the PHE, or end them at an earlier date. With flexibility and additional time to act, states should leverage these options to ensure that their residents have access to affordable coverage during this crisis.

Making Temporary Changes Permanent

As noted above, most of the changes states made in response to the COVID-19 crisis are approved under Medicaid disaster SPAs or verification plan addendums, allowing states to simplify the submission and approval of their changes and adopt certain policies they may wish to make for a limited time period. But most of the underlying policy options that states have temporarily elected, such as expanding PE or eliminating premiums and copayments, are available on a permanent basis. As they experiment with these policies during the pandemic, many Medicaid agencies are finding that they simplify the enrollment process for eligible applicants while reducing burden on caseworkers. Particularly since Medicaid agencies will continue to face increased demand and decreased resources after the PHE, they should make these policies that streamline access to Medicaid permanent.

To continue implementing these changes after the PHE expires, states must submit new SPAs and verification plan addendums following traditional processes, and in some cases, comply with regulatory public notice requirements. States interested in making policies approved under their Medicaid disaster SPAs permanent, including any telehealth changes, will need to submit a new SPA no later than the end of the quarter in which the PHE ends to ensure that the new SPA’s effective date coincides with the end of the PHE.^[32] Before submitting the new SPA, states should ensure that they meet the necessary public notice and tribal consultation requirements. Generally speaking, most eligibility and enrollment SPAs do not require states to solicit public comments, but changing cost sharing, certain benefits, telehealth, and provider rates does require public notice.^[33]

For changes to the state’s verification plans, including post-enrollment verification and increases to the reasonable compatibility threshold, states would have to submit an addendum to their verification plan. The verification plan addendum submission process is straightforward, with a shorter and less complicated CMS review and approval period than for SPAs.