Putting CMS COVID-19 Guidance into Perspective

The COVID-19 pandemic is a stark reminder of the critical role that Medicaid and CHIP play in assuring the health of Americans in crisis scenarios. As we navigate these challenges in the days and weeks ahead, the Centers for Medicare and Medicaid Services (CMS) is offering states unprecedented flexibility to reduce barriers to accessing care.  

CMS has released an FAQ document to aid state Medicaid and CHIP agencies in their response to the COVID-19 outbreak. The guidance outlines the flexibilities granted to these agencies to accelerate pandemic response. Specifically, it addresses guidance around managed care, benefits, financing, 1115 demonstrations, and leveraging 1135 emergency waivers. In this blog, we unpack the key takeaways from the latest CMS guidance and how State Medicaid Agencies (SMAs) can use these insights to accelerate access to care.

Takeaway 1: CMS’ guidance offers increased flexibility in Medicaid and CHIP eligibility and enrollment.

States may expand hospital presumptive eligibility to non-MAGI groups. The Affordable Care Act (ACA) requires states to allow hospitals to make presumptive eligibility determinations for Modified Adjusted Gross Income (MAGI) groups, including children, pregnant women, parents/caretakers, and former foster youth, among others. States may also allow hospitals to make presumptive determinations for groups such as seniors or those with blindness or disability.

Medicaid agencies may be excused from meeting application processing timeliness standards due to administrative or another emergency beyond the agency’s control. During public health emergencies, states may experience workforce shortages, or applicants may be unable to receive or respond to requests for information. The Medicaid timeliness standard exception does not require a state plan amendment (SPA), but states must document the reason for the delay in the individual’s case file. If states seek a timeliness standard exception broadly, they should seek CMS’ concurrence that the flexibility is needed. CHIP agencies must submit a disaster relief state plan amendment to utilize this exception or notify CMS if such a plan is already in place.

If states take advantage of flexibility in meeting timeliness standards for renewals, they must continue to provide coverage until a person is determined ineligible. Like the flexibility regarding application timeliness standards, Medicaid agencies generally don’t need a state plan amendment to use this flexibility for individual cases. Broader adoption requires CMS permission.

States may extend renewal periods for non-MAGI groups. While the ACA requires a 12-month renewal period for MAGI groups, it does not apply to coverage for seniors or individuals with disabilities. States have the option to extend renewals for these groups but cannot do so for a narrow group affected by a diagnosis, such as COVID-19. A state plan amendment is needed to extend the renewal period for non-MAGI groups.

States may stop charging co-payments during a public health emergency, but exemptions from co-payments cannot be applied narrowly based on a diagnosis. To take advantage of this flexibility, Medicaid agencies must file a state plan amendment, and CHIP agencies must utilize a disaster relief SPA.

Applying the latest guidance, SMAs can take a few key steps to promote ease of access to care for enrollees: 

  • Assess current processes. SMAs should rapidly assess their existing processes to determine the appropriate waivers and amendments required to support expanded access to healthcare services for enrollees during the emergency.
  • Adopt agile project management. Following this assessment, SMAs should adopt a focused, agile project management approach to ensure timely delivery of necessary process and system changes.
  • Enable meaningful change. Develop an Organizational Change Management plan that ensures increased external stakeholder awareness, understanding, and acceptance of ways to support increased access to care.
  • Stay connected. The crisis is evolving daily, so continue to monitor guidelines from government and health officials. Applying your agile project management foundation, continuously refine and adapt operational standards as the regulatory landscape evolves.

Takeaway 2: CMS is focusing on ways to facilitate care and reduce financial burden.  

Communicate and encourage the use of services available through Medicaid and CHIP programs. Medicaid and CHIP coverage is comprehensive and includes services that are critical during the current public health crisis. These programs now cover screening and diagnostic services for COVID-19 for all enrolled children and adults. 

CMS broadens access to telehealth during the COVID-19 public health emergency. To increase telehealth access during social distancing efforts, CMS administrator Seema Verma has reiterated that state Medicaid agencies can provide telemedicine services without federal approval. As a companion to the Medicare telehealth guidance, CMS also released Medicaid telehealth guidance to states—aimed at helping states understand the policy options available for provider reimbursement.

With the additional flexibility afforded by CMS to facilitate care and reduce financial burden, SMAs should take the following steps:  

  • Revisit processes for provider reimbursement. Evaluate, implement, and deploy current system rules, code sets, and limitations for claims/encounters processing and provider reimbursement.
  • Tap into telehealth. Assist provider networks with guidance on the development and deployment of telehealth services to beneficiaries.
  • Prepare to gather critical learnings. Prepare for a post-emergency audit to identify and address instances of fraud, waste, and abuse for COVID-19-related services rendered.

Takeaway 3: The latest guidance from CMS highlights the agency’s disaster response toolkit.

The toolkit outlines strategies available to support Medicaid and CHIP agencies and enrollees. The toolkit also describes authority that may be granted under Section 1135 waivers should the President declare an emergency or natural disaster. Following President Trump’s declaration of a national emergency, CMS now has the authority to waive specific requirements in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) under Section 1135. In our recent blog, we explore how states can take advantage of these waivers in improving access to testing and care.

Crises happen. And when they do, governments must respond swiftly to protect the most vulnerable. By taking aggressive advantage of the flexibility permitted by Medicaid and CHIP statutes in the days and weeks ahead, states can help their members obtain the healthcare needed to weather the COVID-19 crisis.