State Medicaid Plans Wrestle With COVID-19

The Medicaid program is undergoing temporary changes as a result of COVID-19, with states doing their best to grapple with the increased need for healthcare access.
President Trump’s declaration last Friday of a national emergency paved the way for temporarily expanded powers of state Medicaid programs achieved through special exemptions known as 1135 waivers. These waivers would allow states to, among other things, make it easier for people to apply for Medicaid and to retain their eligibility, and for states to make sure there are enough healthcare providers to treat people by increasing the scope of allowable telehealth services.

The waivers would also permit states to allow Medicaid enrollees’ treatment to occur in non-traditional settings and relax licensing requirements for out-of-state providers. The waivers also need to make it easier for providers to bill and get paid for services, so they can continue to focus on providing care and be assured of adequate revenues, Christopher Koller, president of the Milbank Memorial Fund, in New York City, said in a blog post earlier this month.
“This has happened in the past, whether it was a natural disaster like a hurricane or a fire or rarely, like what we have now, some sort of national emergency,” Koller said in a phone interview. “For Medicaid to be useful then, the states need permission to reinterpret Medicaid rules around eligibility, enrollment, and covered services, and participating providers.”
Florida Receives First Waiver
On Tuesday, Florida became the first state to receive an 1135 coronavirus-related waiver, which was approved in “a matter of days,” as Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), noted in a White House coronavirus task force briefing Tuesday.

Florida’s waiver “includes flexibilities that enable the state to waive prior authorization requirements to remove barriers to needed services, streamline provider enrollment processes to ensure access to care for beneficiaries, allow care to be provided in alternative settings in the event a facility is evacuated to an unlicensed facility, suspend certain nursing home screening requirements to provide necessary administrative relief, and extend deadlines for appeals and state fair hearing requests,” CMS said in a press release.
Some of the other relief that states may want to see revolves around types of providers and services such as telehealth use, “particularly with something like coronavirus,” Koller said. Many state Medicaid programs “previously had a pretty narrow definition of when telehealth is a covered benefit — only for these types of services, provided by these people.” But in this circumstance, they may want to say that “any service that can be provided using information technology, we want to encourage, because we don’t want to create requirements for people to come in for a face-to-face visit. So that’s another category.”

However, he cautioned, “the federal government isn’t going to approve everything the states are asking for … They have to determine whether it’s reasonable and permissible.”
Different From Other Emergencies
The authorities that Florida received are “terrific,” said Kinda Serafi, JD, partner at Manatt Health, a professional services firm in New York City. The exemptions Florida received are for the most part already authorized in a declaration from Health and Human Services Secretary Alex Azar “and also in guidance CMS had submitted … so this was just a formal inquiry and then confirmation. I think we will see states going way beyond the Florida 1135 waiver request and ask for more things.”
This waiver situation is different than others Medicaid has dealt with because previous emergencies — such as wildfires and hurricanes — have involved only a single state or a few states, Serafi pointed out. “In that circumstance, there is bandwidth in the state and the federal government to collectively think about what are the flexibilities a state needs. This is bigger and more global, and it will be interesting to see how states are responding” when they need to bring the hospital association and other state medical groups together to figure out what they should be asking CMS for. “When it’s a one-state problem, you can have the whole CMS team on the phone and helping negotiate a rapid response, but now you’ve got 50 states plus.”

Robin Rudowitz, co-director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation here, pointed out that the bill passed early Saturday by the House and now being considered by the Senate includes a provision for a temporary increase of 6.2 percentage points in the federal Medicaid matching rate for each state. “To access the enhanced matching funds, states need to meet certain requirements, so they’re not allowed to implement more restrictive eligibility requirements or standards … and they’re also not allowed to impose cost-sharing for testing or treatment for anything related to COVID-19,” she said.
The COVID-19 pandemic might also give the 14 states that haven’t expanded Medicaid under the Affordable Care Act a reason to reconsider, she added. “That is something they can do that certainly would reduce the number of uninsured in their state,” and the federal government would provide 90% of the funds needed for the expansion.

Issues for Communities of Color
A recent telephone briefing by the NAACP highlighted some of the issues states will be facing with disadvantaged enrollees, including those in communities of color.
Nicolette Louissaint, PhD, executive director of Healthcare Ready, a non-governmental organization here, spoke about the impact of the virus among the “medically fragile,” or patients with more severe illness or chronic illness, and the “socially vulnerable,” those who may not be infected by the coronavirus, but may be challenged by the downstream effects of the public health response.
“In order to … flatten the curve, we’re going to have to change lifestyles,” she said, describing the outbreak as a “long-haul, sustained event.”
Louissaint cited statistics showing that while 46% of the population relies on prescription drugs and has used them in the last 30 days, that number jumps to 85% for people of color. In fact, she said that 30% of people of color are not able to last 1 day without medication.

“We need to make sure that individuals who need [healthcare] continue to have access to it and can do it safely,” such as patients with end-stage renal disease who need dialysis daily. “Making sure healthcare is accessible to everyone is incredibly important.”
https://www.medpagetoday.com/infectiousdisease/covid19/85473