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Responding to COVID Through Medicaid Waivers: A New Search Tool

Medicaid and the Children’s Health Insurance Programs (CHIP) provide health insurance coverage to more than 70 million people in the U.S.  Medicaid is administered by the states according to federal requirements, and is jointly funded with total spending reaching nearly $600 billion.  Although the federal government requires that certain low-income groups be covered, including low-income families, qualified pregnant women and children, and people with disabilities, states may choose to cover other low-income individuals. Thirty-seven states, including Virginia, opted to expand Medicaid coverage to low-income working-aged adults under the Affordable Care Act.  States may also provide additional services beyond those that are federally required (inpatient and outpatient hospital care, physician visits, laboratory and x-rays, and home health).  With over 21 million people currently out of work and the unemployment rate at over 13% as a result of COVID-19, the number of individuals eligible for Medicaid is expected to rise as wages decrease and people lose their employer-sponsored health insurance coverage. 

How are state Medicaid programs adapting to this increased need during the pandemic, and what are they doing to ensure eligible people receive services?  The answer is that states are using various approaches to increase access and address Medicaid coverage issues. State officials develop different response plans to COVID-19 based on their varying motivations, which may include, among other things, the desire to “quickly increase their health care workforces”, “stabilize enrollment to reduce the likelihood of interrupted coverage”, “ensure that sufficient health care items and services are available to meet [beneficiaries’] needs”, secure “financial stability for providers so they can keep their doors open and serve their communities”, “promote flexible care arrangements”, and “encourage all members to seek needed medical care and treatment” for suspected COVID-related illness.  This article describes some of the strategies states are using, and some resources that can help researchers eventually study and learn from these state responses.

Changes Across the States

In declaring COVID-19 to be a “national emergency” on March 13, 2020, President Trump authorized the U.S. Secretary of Health and Human Services to “temporarily waive or modify certain requirements” of the Medicaid program.  As a result, states may now request changes to their Medicaid programs through Medicaid Disaster Relief State Plan Amendments (SPAs), other administrative actions, and a series of existing waiver authorities (Section 1115, Section 1135, and Section 1915c Appendix K).  To understand the unique approaches taken by each state, the Kaiser Family Foundation (KFF) has aggregated “approved Medicaid emergency authorities to address the COVID-19 Coronavirus emergency.”  

KFF describes state actions authorized under SPAs and through waivers.  Actions taken by the states under SPAs are provided in 10 broad areas:  eligibility, enrollment, appeals, premiums and cost sharing, benefits, prescription drugs, telehealth, payments, providers, and oversight.  For each action, KFF lists the number and names of states taking such action and the method the states took to affect the change (temporary change under the state’s approved disaster-relief SPA, approved SPA, or other state-reported actions). 

Waivers allow states to make both big and small changes to their Medicaid programs.  For example, under approved Section 1135 waivers to address COVID-19, all states and DC may waive certain provider screening requirements, postpone deadlines for revalidation of providers, and allow out-of-state providers with equivalent licensing in another state.  Forty-four states may allow service provision in alternative settings, including unlicensed facilities, and 43 states may suspend fee-for-service prior authorizations.  Twenty-one states may allow verbal consent in lieu of written signatures for home and community-based services, and five states may allow face-to-face encounters for home health services to take place up to 12 months after the start of service.  Through approved Section 1115 waivers, the state of Washington may “target services on a geographic basis that is less than statewide,” and may vary the amount, duration, and scope of services based on population needs. Under approved Section 1915(c) Appendix K waivers, 29 states may temporarily modify service scope or coverage; 15 states may add home delivered meals; 13 states may add medical supplies, equipment, and appliances; 38 states may prohibit visitors at any time to minimize the spread of infection; 30 states may temporarily increase payment rates to providers; and 9 states may track COVID-19 cases among waiver enrollees.

Changes Within Virginia

In Virginia, about 30,000 adults have enrolled in Medicaid since Governor Northam issued a COVID-19 emergency declaration in March.  To respond to COVID-19 and to ensure access to care for Medicaid beneficiaries, Virginia has taken a series of steps.  The Commonwealth, for example, successfully received a Section 1135 waiver, which allows for, among other things, no pre-approvals for certain critical medical services and devices, the removal of long-term services and supports screening for people who choose to move to a nursing facility directly from a hospital, and the ability of home health and hospice aides to provide services without in-person supervision by a registered nurse every two weeks.  In addition, Virginia’s Governor permitted executive branch agency directors, including the director at Virginia’s Medicaid agency, the Department of Medical Assistance Services (DMAS), to make the changes necessary to respond to the pandemic (for DMAS waivers click here and click here).  The waivers were designed in part to “minimize face-to-face contact during the emergency”, ease the burden on providers, “ensure beneficiaries receive continuity of care”, address “provider shortages related to in-home services”, “maintain the sufficiency of available provider networks”, and “maximize access to care while minimizing viral spread through community contact.”  Virginia’s Medicaid program now covers all COVID-19 testing and treatment, ensures that no Medicaid member loses coverage, eliminates co-payments on all Medicaid covered services, encourages use of telehealth, and provides a 90-day supply of routine prescriptions. 

As a result of COVID-19, total projected Medicaid spending will likely surpass the $600 billion currently spent nationally and the nearly $9 billion spent on Medicaid services in the Commonwealth. Nationwide, over 31 million people had filed for unemployment insurance between March 1 and May 2, 2020.  According to a recent KFF analysis, unemployment insurance benefits may run out for most of these individuals by January 2021, perhaps resulting in nearly 17 million people becoming newly eligible for Medicaid.  As the coronavirus pandemic continues, states will continue to look for ways, including the continued use of emergency waiver authorizations, to improve access and maintain Medicaid coverage for these potential newly-eligible state residents.