As states nationwide escalate efforts to deal with the COVID-19 pandemic, State Medicaid Agencies (SMAs) are playing a critical role by removing barriers to care. The President declared the outbreak a national emergency on March 13, 2020, which gave the Centers for Medicare and Medicaid Services (CMS) authority to waive certain requirements in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) under Section 1135 of the Social Security Act. Through a combination of blanket and state-specific waivers, CMS has the authority to provide SMAs with flexibility to bypass certain administrative requirements in the interest of expanding access to Medicaid coverage.
Florida was the first state to submit a Section 1135 emergency waiver request, which CMS granted within days of submittal. Shortly after, CMS approved a waiver for Washington State. At the time of this writing, many other states have received or are seeking approval for their waiver requests. States are also exploring solutions other than waivers; for example, New Jersey submitted a request to CMS to authorize a Special Enrollment Period (SEP) before their 1135 waiver was approved. The policy tools available to SMAs through 1135 waivers and other emergency measures include tactics to increase the number of people able to enroll in Medicaid, as well as the number of healthcare providers and the range of covered treatments (e.g., telemedicine). The Section 1135 waiver provisions outlined below are common to Florida and Washington, and other states may implement similar approaches to remove administrative barriers to care.
Expanding Access to Care
The Florida and Washington waivers allow these states to accept provider enrollments from another State Medicaid Agency (SMA) and/or Medicare. This flexibility allows providers from outside of these states to offer treatment to beneficiaries within the state, and subsequently receive reimbursement for those services without going through the Medicaid enrollment process, thereby quickly expanding access to care.
Florida’s waiver provides additional flexibility for providers not already enrolled with another SMA or Medicare by waiving several of the time-consuming screening requirements, including:
- Payment of the application fee
- Criminal background checks associated with fingerprint-based criminal background checks
- Site visits
- In-state territory/licensure requirements
As states relax their provider enrollment and screening processes in the interest of public health and care, protecting those most vulnerable is a benefit that far outweighs any risks to program integrity. When the pandemic has abated and Medicaid program operations return to a more stable condition, SMAs can then shift resources away from crisis management to the more routine processes of identifying and taking corrective action on fraud, waste, and abuse. It is also worth noting that state Medicaid agencies should modify their Medicaid Management Information System (MMIS) provider enrollment process to implement the approved waiver provisions for relaxed provider enrollment.
The Florida and Washington waivers also provide relief for specific procedures in the Medicaid fee-for-service delivery model, allowing services which typically require a prior approval to be allowed for a specified duration. As this allowance is specific to fee-for-service claim submissions, existing MMIS claims processing edits and audits will need to be re-configured to allow for the changes. Otherwise, claims will be incorrectly denied, or have other unintended negative downstream impacts in other areas of claims processing. Planning for these changes will need to be robust, thoughtful, and forward-thinking. Since the allowances outlined in the 1135 waivers are time-boxed, any system changes to accommodate the waivers will need to revert back to the previous configurations to support post-pandemic, business-as-usual processes.
The CMS approval letters linked towards the bottom of this article contain additional detail and explanation of the specific waivers granted to each state. While each of these allowances became immediately effective as outlined in the dates listed in the CMS approvals, the systematic and policy changes needed to enact each of these processes will take time before they go live. As states transition from their legacy MMIS to modular Medicaid Enterprise Systems (MES), they will be in a position to more rapidly respond to future public health emergencies; for example, by using near-real-time data to identify gaps in provider network adequacy to direct a targeted response.
Accelerating Your Response
To continue playing a meaningful role in slowing the spread of COVID-19, there are a few key steps that SMAs can take in the context of the current regulatory environment:
- Stay informed about the policy tools available. Familiarize yourself with the Medicaid Disaster Response Toolkit and monitor CMS approved waiver provisions for other states.
- Make adequate preparations for system changes. Work with your current fiscal agents or other vendors to ensure the MMIS enhancements/modifications are completed and tested as timely, efficiently, and effectively as possible.
- Communicate with counterparts in other states. Learn from other state’s experiences and share your lessons from waiver implementation, management, and tracking.
As more states ramp up their efforts to halt the spread of COVID-19, it is important that each SMA understands the various steps that CMS and other states are taking to mitigate the situation as quickly as possible. CMS has proven that it is taking proactive steps to increase and accelerate accessibility to healthcare to some of the neediest populations. A coordinated and collaborative effort at the federal and state levels will be key to slowing the spread of the virus as soon as possible.
CMS Press Release on Section 1135 Waivers
CMS COVID-19 Emergency Declaration Health Care Providers Fact Sheet
CMS Section 1135 Waiver Request Template for COVID-19
New Jersey Special Enrollment Period (SEP) Letter
Medicaid Disaster Response Toolkit
Kaiser Family Foundation (KFF) Data and Policy Actions to Address Coronavirus and State Tracker