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States Are Leveraging Medicaid to Respond to COVID-19

UPDATED
May 20, 2020

"Congress should support states in making these changes by further increasing Medicaid’s federal match rate."Many state Medicaid programs are proposing or implementing new policies to respond to COVID-19 and maintain access to health care during the public health crisis. States are strengthening their home- and community-based services (HCBS) programs, improving access to coverage and care, helping people access care while social distancing, and ensuring financial stability for providers so they can keep their doors open and serve their communities. More states should consider implementing these policies, especially as more people lose their jobs or incomes and need Medicaid coverage. Congress should support states in making these changes by further increasing Medicaid’s federal match rate to defray the cost of these policies, as well as to prevent states from reducing access to care.

States Are Implementing New Medicaid Policies to Respond to COVID-19

Every state has made at least one change to its Medicaid program in response to COVID-19, using various available Medicaid authorities (see the textbox below).[1]

Expanding or Strengthening HCBS for Seniors and People With Disabilities

HCBS are especially important during the public health crisis because they help seniors and people with disabilities remain in their homes, where they are generally safer from the virus than in nursing homes.

To date, the Centers for Medicare & Medicaid Services (CMS) has approved section 1915(c) waiver Appendix K changes to HCBS in 42 states (see Table 1 for a list of changes by state). These changes are making it easier for seniors and people with disabilities to get HCBS. More than half of states are permitting providers to conduct virtual assessments and person-centered planning meetings, modifying processes for level-of-care evaluations, extending reassessment and re-evaluation dates, and modifying the person-centered planning process.

States are also using these approvals to expand services by allowing beneficiaries to receive services beyond the typical limits, adjusting prior authorizations, adding new services and supplies such as home-delivered meals and adaptive technology, and allowing HCBS to be provided in alternative settings such as hotels, schools, churches, and temporary shelters.

Finally, states are strengthening the HCBS workforce by increasing payment rates, providing retainer payments to help keep HCBS providers stay in business, and paying family caregivers.

State Pathways to Implement New Policies

Medicaid agencies can use four main pathways to implement new policies to respond to COVID-19. Some of these pathways rely on temporary authorities linked to the public health emergency (PHE) declared by Health and Human Services (HHS) Secretary Alex Azar, and the Stafford Act Emergency Declaration issued by President Trump.a

  • Medicaid state plan amendments are usually the simplest and quickest way for states to make changes. Each state has a plan describing its rules related to Medicaid eligibility, benefits, cost sharing, and payments, and states have significant latitude to modify these plans.b
  • Section 1135 waivers are special waivers available only after both the President and HHS Secretary have declared a national emergency. In addition to certain blanket waiver authorities, section 1135 waiver authority allows the Secretary to waive or modify certain Medicaid requirements to ensure that health care items and services are sufficient to meet the needs of enrollees in areas affected by a PHE.c
  • Emergency section 1115 waivers are available after the Secretary has declared a national emergency and relieve states from certain requirements that usually apply to 1115 waivers, like demonstrating budget neutrality and public notice and comment procedures. Emergency section 1115 waivers can be used to implement policies not otherwise allowed under Medicaid law, such as expanding benefits and streamlining enrollment processes.d
  • Section 1915(c) waiver Appendix K is an approach states can use during emergencies to amend HCBS programs authorized under approved section 1915(c) waivers, the authority states generally use to implement HCBS. Appendix K changes can be retroactive and the section 1915(c) public notice requirements don’t apply to such requests.e

a For more information on these pathways, see Jennifer Wagner, “Streamlining Medicaid Enrollment During COVID-19 Public Health Emergency,” Center on Budget and Policy Priorities, April 7, 2020, https://www.cbpp.org/research/health/streamlining-medicaid-enrollment-during-covid-19-public-health-emergency.

b CMS issued a disaster state plan amendment template that lets states change their Medicaid state plans quickly; see https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/state-plan-flexibilities/index.html.

c Section 1135 templates are available at https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/section-1135-waiver-flexibilities/index.html, and approved waivers can be viewed at https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/federal-disaster-resources/index.html.

d CMS has issued an emergency section 1115 waiver template, which is available at https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html.

e CMS has issued an appendix K template, which is available at https://www.medicaid.gov/state-resource-center/downloads/sample-appendix-k-template.docx.

Improving Access to Coverage and Care

States are using disaster-related state plan amendments (SPAs) and administrative actions to make it easier for people to enroll in coverage (see Table 2). For example, some states are electing the new eligibility group authorized under the Families First Act Coronavirus Response Act to cover COVID-19 testing for uninsured individuals and using less restrictive methodologies to determine eligibility.

Some states are also accepting self-attestation for all eligibility criteria covering non-residents or people living temporarily out of state due to the public health emergency, adopting a simplified/streamlined application, giving non-citizens more time (a longer reasonable opportunity period) to document their eligibility for coverage, and expanding presumptive eligibility (which lets providers and other qualified entities temporarily enroll people who appear eligible for Medicaid) to new populations, including seniors and people with disabilities.

States are also expanding coverage and making it more affordable by adjusting or increasing benefits, covering COVID-19 testing or treatment through emergency Medicaid, and eliminating copayments and other cost-sharing charges as well as premiums.

Helping People Access Care While Maintaining Social Distance

States are using a combination of disaster SPAs, administrative actions, and section 1135 waivers to maintain access to health care while people are social distancing (see Table 3). For example, states are expanding the use of telehealth by waiving or reducing telehealth copayments, paying some telehealth services at the same rate as face-to-face visits, waiving or reducing copayments for telehealth services, and giving providers more flexibility to provide telehealth services.

States are also using these authorities to prevent unnecessary trips to the doctor or pharmacy by suspending or extending prior authorizations for health care services and items, allowing Medicaid beneficiaries to get early prescription drug refills, increasing the maximum supply or quantity limit of certain drugs, making changes to preferred drug lists, and waiving or suspending prescription drug prior authorizations.

Expanding or Strengthening the Health Workforce

CMS has approved disaster SPAs that allow states to increase payment rates and supplemental payments to certain providers (see Table 4). And nearly all states are using section 1135 waivers to make it easier for providers to enroll in their Medicaid programs, allow out-of-state providers to furnish services, and allow providers to offer health care services in alternative settings, including unlicensed facilities.

States Need More Medicaid Funding to Support Their Efforts

While some of the policies above are low cost, others are expensive to implement. Congress should support states in their efforts to respond to COVID-19 by further increasing Medicaid’s federal match rate to help them cover these additional costs. Increasing the federal match rate will also help prevent people from losing access to critical services during the public health and economic crises.[2]

TABLE 1
Strengthening Home- and Community-Based Services (HCBS)
  Making It Easier to Get HCBS Expanding Services & Settings Strengthening HCBS Workforce
State Permitting Virtual Assessments & Person-Centered Planning Meetings Modifying Processes for Level-of-Care Evaluations Extending Reassessment & Re-evaluation Dates Modifying Person-Centered Planning Process Adjusting Service Limits Adjusting Prior Authorizations Adding Services to Address Emergency1 Allowing HCBS in Alternative Settings Expanding Paid Family Caregiver Limits Increasing Payment Rates Making Retainer Provider Payments
Alabama                      
Alaska   X X X X X   X X X X
Arizona X   X X   X X X X   X
Arkansas                   X  
California X X X X       X X   X
Colorado X X X   X X X X X X X
Conn. X X X   X X X   X X X
DC X X X X X X   X X X X
Delaware X X X       X X X X X
Florida X   X   X X X X X   X
Georgia X X X X X X   X X X X
Hawaii X X X X X   X X     X
Idaho                      
Illinois X   X X X X X X X X X
Iowa X X X   X X X X     X
Indiana                      
Kansas X   X   X X X X X    
Kentucky X X X X X X   X   X X
Louisiana X X X X X X X X X X X
Maine X X X X X   X X X X  
Maryland X X X X X X   X X X X
Mass. X X X X X X X X   X X
Michigan                      
Minnesota X X X         X   X  
Mississippi X X X X X   X X X X  
Missouri                      
Montana X X X X X X X X X   X
Nebraska X X X X X X   X   X X
Nevada X X X X X X X X X   X
New Hampshire X X X X X X   X X   X
New Jersey                      
New Mexico X X X X X X X X X   X
New York X X X X X X   X   X X
North Carolina X X X X X   X X X   X
North Dakota X X X X X X   X X X X
Ohio X X X X X X          
Oklahoma X X X X X X X X X   X
Oregon X X X X       X   X X
Penn. X X X X X X X X X X X
Rhode Island X X X X              
South Carolina X   X X X   X X X    
South Dakota X   X X X X   X X   X
Tenn. X X X X   X X X   X  
Texas                      
Utah X   X X X X   X X   X
Vermont                      
Virginia X   X         X X   X
Washington X X X X X X X X   X X
West Virginia X X X X X X   X X   X
Wisconsin                      
Wyoming X X X   X     X   X  
Total 40 33 37 32 33 28 21 39 29 24 32

1 CO, CT, DE, FL, HI, IA, IL, KS, LA, MA, ME, MS, MT, NC, NV, PA, SC, and WA have temporarily added services to address the emergency. AZ, CT, DE, IA, KS, LA, MA, MS, OK, and SC have added home-delivered meals. CO, DE, HI, KS, MA, MS, NC OK, PA, and TN have added medical supplies, equipment and appliances, and KS, LA, MA, NM, and OK have added assistive technology.

TABLE 2
Improving Access to Coverage and Care
  Making It Easier to Enroll in Coverage Expanding Coverage & Making It More Affordable
State Electing New Uninsured Eligibility Group Accepting Self-Attestation Permitting PHE-related Out-of-State Temporary Residency & Coverage for Non-Residents Using Less Restrictive Methodologies to Determine Eligibility Expanding PE Using Simplified Application Extending Reasonable Opportunity Period Adjusting or Increasing Existing Benefits Covering COVID Testing or Treatment Through Emergency Medicaid Eliminating Copays Eliminating Premiums
Alabama X             X   X  
Alaska     X       X X     X
Arizona X         X   X   X X
Arkansas               X      
California X X   X X     X X   X
Colorado X             X     X
Conn. X               X    
DC                      
Delaware                 X    
Florida               X   X  
Georgia                   X  
Hawaii                      
Idaho                   X X
Illinois X X   X X         X X
Iowa X   X   X         X X
Indiana                   X X
Kansas         X   X        
Kentucky           X       X  
Louisiana X X X       X X   X  
Maine X X X             X X
Maryland               X     X
Mass. X X   X X       X    
Michigan                 X    
Minnesota X                   X
Mississippi                      
Missouri   X   X           X  
Montana X                    
Nebraska     X   X   X     X  
Nevada                      
New Hampshire X                    
New Jersey                      
New Mexico X X     X            
New York                 X    
North Carolina   X X         X     X
North Dakota                     X
Ohio   X                  
Oklahoma                      
Oregon             X   X    
Penn.   X X       X X X    
Rhode Island X   X       X        
South Carolina X                 X  
South Dakota                      
Tenn.                      
Texas X                    
Utah X       X            
Vermont   X   X           X X
Virginia     X       X     X  
Washington X X X X X X   X X   X
West Virginia X                    
Wisconsin         X           X
Wyoming   X                 X
Total 20 13 10 6 10 3 8 12 9 16 17

Note: PHE = public health emergency; PE = presumptive eligibility

TABLE 3
Helping People Access Care While Social Distancing
  Expanding Telehealth Preventing Unnecessary Trips to the Doctor or Pharmacy
State Waiving or Reducing Copays Payment Parity w/ Face-to-Face Visits Greater Provider Flexibility to Furnish Telehealth Suspending Prior Authorizations for Certain Health Care Services Extending Prior Authorizations for Certain Health Care Services Allowing Early Refills Increasing Quantity Limits of Certain Drugs Making Changes to Preferred Drug Lists Waiving or Suspending Drug Prior Authorizations
Alabama   X X   X          
Alaska   X X X X X X X X  
Arizona X   X X X X X X X  
Arkansas   X X X   X X X    
California X X X X X X X   X  
Colorado X X X X X X X      
Conn. X   X X X X X      
DC   X X X X X X X X  
Delaware   X X X X X X      
Florida   X X X X X X      
Georgia     X X X X X   X  
Hawaii   X X X            
Idaho     X X X          
Illinois   X X X X X X X X  
Iowa X X X     X X      
Indiana   X X X X X X X X  
Kansas     X X X   X X X  
Kentucky X X X X   X X      
Louisiana     X   X X X X X  
Maine   X X X X X X X X  
Maryland   X X X X X X      
Mass. X X X X X X X   X  
Michigan     X X X          
Minnesota   X X X     X      
Mississippi   X X X X          
Missouri X X X X X X   X X  
Montana   X X X X   X X X  
Nebraska   X X X X X        
Nevada   X X   X X        
New Hampshire X X X X X X     X  
New Jersey X X X X X X X      
New Mexico X X X X X X X      
New York X X X X X X X   X  
North Carolina X X X X     X X X  
North Dakota X X X X X   X X X  
Ohio     X X   X X   X  
Oklahoma X   X X     X   X  
Oregon   X X X X X        
Penn. X   X X X X X      
Rhode Island X X X X X X X X X  
South Carolina X X X   X X        
South Dakota   X X     X X   X  
Tenn.   X X     X X   X  
Texas X X X   X X X      
Utah   X X X   X        
Vermont X X X X X X X   X  
Virginia     X X X X X      
Washington   X X X X     X    
West Virginia     X X X   X      
Wisconsin   X X X X X X      
Wyoming   X X X            
Total 20 39 51 43 39 37 37 15 23  
 
TABLE 4
Strengthening the Health Care Workforce
State Increasing Provider Payments Easing Provider Enrollment Requirements Allowing Out-of-State Providers to Provide Care Allowing Providers to Offer Services in Alternative Settings
Alabama X X X  
Alaska   X X X
Arizona X X X  
Arkansas X X X  
California   X X X
Colorado X X X X
Conn.   X X X
DC   X X X
Delaware   X X  
Florida   X X X
Georgia   X X X
Hawaii   X X X
Idaho   X X X
Illinois X X X X
Iowa   X X X
Indiana   X X X
Kansas   X X  
Kentucky X X X X
Louisiana X X X X
Maine X X X X
Maryland X X X X
Mass. X X X X
Michigan   X X X
Minnesota   X X X
Mississippi   X X X
Missouri   X X X
Montana X X X X
Nebraska   X X X
Nevada   X X X
New Hampshire   X X X
New Jersey   X X X
New Mexico X X X  
New York   X X X
North Carolina X X X X
North Dakota   X X  
Ohio   X X X
Oklahoma   X X X
Oregon   X X X
Penn.   X X X
Rhode Island X X X X
South Carolina X X X X
South Dakota   X X X
Tenn.   X X X
Texas   X X  
Utah   X X X
Vermont   X X X
Virginia   X X X
Washington X X X X
West Virginia   X X X
Wisconsin   X X X
Wyoming   X X X
Total 16 51 51 43
 

End Notes

[1] For a complete list of approved state policies, see Kaiser Family Foundation, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” accessed on May 20, 2020, https://www.kff.org/medicaid/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/.

[2] Aviva Aron-Dine et al., “A Larger, Longer-Lasting Increases in Federal Medicaid Funding Needed to Protect Coverage,” Center on Budget and Policy Priorities, May 5, 2020, https://www.cbpp.org/research/health/larger-longer-lasting-increases-in-federal-medicaid-funding-needed-to-protect.