Mar, 11, 2020

State Medicaid and CHIP Strategies to Respond to the COVID-19 Public Health Crisis

Patricia Boozang and Kinda Serafi, Manatt Health

As concerns regarding widespread COVID-19 (Coronavirus) infection in the United States increase, state Medicaid and Children’s Health Insurance Program (CHIP) agencies are evaluating how to leverage their public health insurance programs to respond. Medicaid and CHIP agencies are dusting off disaster preparedness toolkits and inventory checklists that were originally prepared to respond to hurricanes, floods and wildfires and tailoring those strategies to address the impacts that COVID-19 will likely have on Medicaid/CHIP enrollees, providers and state agency workforce. This expert perspective discusses strategies state Medicaid and CHIP agencies can pursue as part of their emergency preparedness planning for, and response to, COVID-19.

Eliminate Cost Sharing Barriers to Testing and Care. Similar to actions taken recently in New Jersey and New York’s Medicaid and commercial insurance market through the promulgation of emergency regulations,  states can eliminate co-payments for Medicaid enrollees seeking COVID-19 testing or care at a physician’s office, urgent care or emergency room.  Because states are not permitted to target co-payments based on a disease or diagnosis, states that want to suspend co-payments related to COVID-19 testing, treatment and care will need to temporarily suspend co-payments for all services to ensure comparability. Such a modification requires a change to the state’s Medicaid Cost Sharing State Plan Amendment (SPA); states may submit a SPA and implement changes prior to the Centers for Medicare & Medicaid Services (CMS) approval so long as the SPA is submitted within the quarter in which the change was implemented. State Medicaid and CHIP programs may also suspend monthly premiums to ensure there are no barriers to continuity of coverage for enrollees. States with Medicaid premiums authorized through an 1115 waiver will need to formally notify CMS of the temporary suspension and update any implementation protocols; states seeking to suspend monthly CHIP premiums, enrollment fees or co-payments are required to submit a CHIP Disaster Relief SPA.

Ensure Timely Access to Health Care Services. In an effort to ensure that individuals who are sick receive timely health care, states should also consider suspending existing prior authorization or utilization management policies that may impede access. For example, similar to recent action taken in Washington through  an emergency order, states may want to temporarily suspend prior authorization requirements in fee-for-service and Medicaid and CHIP managed care for treatment related to testing and treatment of COVID-19.  California also recently released an All-Plan Letter reinforcing plans’ obligations under existing state authority to cover all medically necessary treatment, including treatment for COVID-19, without prior authorization. States may also require Medicaid and CHIP managed care plans to extend existing prior authorizations for services like home care, oxygen, etc. in the event of disruption to prior authorization activities. Such a modification requires an administrative directive to plans. To ensure access to prescriptions, states may consider temporarily suspending or increasing (e.g. to a 90-day supply) limits on prescription refills in order to ensure that consumers have an adequate supply of their medications in the event of widespread social distancing measures. States would need to look to their current State Plan and identify any current pre-fill limits that would need to be amended in their SPAs.

Address a Compromised Provider Workforce. If health care providers become sick and/or quarantined and are unable to treat patients, states may seek 1135 waiver authority which authorizes the Secretary of Health and Human Services to waive or modify certain requirements in order to ensure there is sufficient access to health care items and services in the event of an emergency. To trigger 1135 waiver authority, the President of the United States must declare a national public health emergency, which has not yet occurred. Under 1135 waiver authority, states can temporarily streamline Medicaid and CHIP provider screening requirements, such as application fees and site visits, to ensure there is a sufficient number of providers available to serve program enrollees. 1135 authority can also be used to allow out-of-state providers to work in neighboring states if they are licensed by Medicare or another state Medicaid agency. Further, states can leverage 1135 waiver authority to enable hospitals and health systems to provide services in alternative settings, such as a temporary shelter. To ensure enrollees have adequate access to providers, states can follow Washington’s lead and direct their Medicaid managed care plans to temporarily suspend out-of-network requirements if they do not have sufficient providers in their network to provide testing and treatment for COVID-19. Washington relied on its current network adequacy statutory requirements to support its directive.

Leverage Telehealth to Treat Medicaid/CHIP Enrollees Remotely. To support remote diagnosis and treatment of enrollees and reduce the risk of exposure to providers, states can review their current Medicaid and CHIP telehealth policies and permit coverage for telehealth services, expand eligible technologies to include services delivered via video, telephone, and email messages, establish a patients’ home as the originating site, and ensure provider payment parity so that telehealth services are reimbursed at the same rate as in-person services. Per CMS guidance, states are not required to submit a separate SPA for coverage or reimbursement of telemedicine services if they elect provider payment parity. CMS plans to issue sub-regulatory guidance on what states will be required to do, if anything, to memorialize changes made to their Medicaid/CHIP telehealth policies.

Partner with Medicaid/CHIP Managed Care Plans to Communicate with Enrollees and Providers.  As states seek to share rapidly evolving information with their enrollees and providers, they can look to partner with their Medicaid managed care plans as part of their communication strategy. For example, New York recently issued a directive to managed care plans to provide specific guidance and education to their members and providers on COVID-19 prevention, treatment and coverage.

Prepare for a Diminished State Agency Workforce. In the event thatMedicaid and CHIP eligibility workers themselves are sick and/or unable to travel to work, states may use potential strategies to streamline enrollment processes. For example, under current Medicaid regulatory authority states can temporarily delay renewal processing in emergency situations. This potential action may be necessary to maintain continuity of coverage in the face of a potential surge in new application volume as consumers increasingly seek health coverage in response to the unfolding public health crisis, and with diminished agency capacity to process applications and renewals.

Coverage for the Uninsured. Separate and apart from the need to respond to diminished workforce capacity, states may consider suspending renewal processing to minimize churn and ensure continuity of health coverage during the public health emergency. Additionally, states that have not expanded Medicaid may have new imperatives to consider expansion in light of the COVID-19 crisis, which is unlikely to resolve in the near-term. States that expand Medicaid coverage up to 138 percent of the federal poverty level (FPL) would need to submit Eligibility, Federal Medical Assistance Percentages (FMAP) and Alternative Benefit Plan (ABP) SPAs, and would receive enhanced federal reimbursement provided for under the Affordable Care Act (ACA). States that elect to expand coverage to an eligibility less than 138 percent of the FPL would be required to submit Eligibility and ABP SPAs only, and would receive their regular matching rate. For hospitals and other providers that provide emergency treatment for undocumented immigrants, states can look to their policies related to Emergency Medicaid coverage to see if there are any state administrative changes that could be made to ensure access for undocumented immigrants to emergency COVID-19 testing, treatment and care consistent with federal requirements.