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State Medicaid Strategies to Maintain Access to Care for Children with Special Health Care Needs during the Pandemic

States and the federal government are taking unprecedented steps to address the health needs of individuals impacted by COVID-19, including children and adults with chronic and complex health care conditions who are vulnerable to infection and to changes in the health care delivery system that may impact their ability to access much-needed primary and specialty care, home- and community-based services.

States are modifying Medicaid policies and programs so individuals and their families can continue to access critical services during the pandemic.

Nearly 20 percent of US children up to 18 years (14.6 million) have a chronic or complex health care need that requires physical and behavioral health care services and supports beyond what children normally require. Medicaid plays a crucial role in providing coverage for children and youth with special health care needs (CYSHCN), serving almost half of the CYSHCN population (48 percent).

The Centers for Medicare & Medicaid Services (CMS) recently released guidance to states outlining strategies, existing federal authorities, and authorities granted through Section 1135 waivers – waivers that are only available to states during an emergency or natural disaster. The 1135 Medicaid emergency waiver, emergency Medicaid State Plan Amendments (SPAs), and 1915(c) Appendix K authorities enable states to implement temporary policies to help maintain access to care during the pandemic. There are also additional steps states can take without CMS approval to help ensure CYSHCN and their families can access services during the pandemic.

Relaxing prior authorization requirements: State Medicaid programs may require that certain services, such as behavioral health and home health services, receive prior authorization before being approved for Medicaid reimbursement. For children, these prior authorization processes will also determine if services are medically necessary and therefore are covered under the Medicaid Early and Periodic Screening, Diagnostic, and Treatment benefit. Using a 1135 waiver, states can temporarily waive prior authorization requirements for services or extend existing prior authorizations for services to help ensure that CYSHCN are able to access needed services through Medicaid providers without prior authorization delays. CMS does note that states can amend their prior authorization policies in fee-for-service delivery systems and can direct managed care organizations to do so without CMS approval. SPAs may be needed depending on the goal and scope of services included. For example, if a state wanted to waive or extend prior authorizations for prescriptions, it may need an SPA to change the quantity authorized.

Closing home health services gaps: Using the 1915 (c) Appendix K waiver authority, states can expand the number of qualified Medicaid providers by loosening qualifications, including permitting payment for services rendered by family caregivers or legally responsible individuals, if this strategy is not already included in their waiver. This strategy can be a welcome support to family caregivers in a time of crisis who otherwise might not be able to access home-based care. Alaska’s approved 1915(c) Appendix K waiver includes provisions that allow providers to hire family caregivers as direct service workers when “regular staffing for services approved in a support plan cannot be assured.” The services include respite care, supportive living services, and in-home supports. One of West Virginia’s approved waivers allows for legal representatives to be paid as personal attendants “should the member’s primary caregiver become unable to provide services/supports.” Five other states (ColoradoConnecticutKansasNew Mexico, and Pennsylvania) have included payment for family caregivers in their approved 1915(c) Appendix K waivers for some, if not all, of their 1915(c) waivers.

Extending timelines for Medicaid fair hearings and appeals: When prior authorization for services is denied, Medicaid enrollees are entitled to appeal and a fair hearing process. Under the 1135 waiver authority, states can extend the 90-day timeframe for enrollees to request a fair hearing to 120 days. This extended timeline can help provide families of CYSHCN with additional time to have denied services reviewed for approval during a fair hearing. To date, 39 states have included this provision in their approved 1135 waivers.

Increasing opportunities for telehealth: CYSHCN often need to access primary and multiple specialty providers on a regular basis to manage and treat their condition. With COVID-19 impacting the ability of providers to conduct typical office hours and the need for CYSHCN with potentially compromised immune systems to limit their time outside of the home, telehealth services are a valuable alternative for care. States are taking steps to make accessing services via telehealth easier, and CMS has encouraged states to increase the use of telehealth services. According to federal guidance, “No federal approval is needed for state Medicaid programs to reimburse providers for telehealth services in the same manner or at the same rate that states pay for face-to-face services. A SPA would be necessary to accommodate any revisions to payment methodologies to account for telehealth costs.” Alabama recently sent a memo to providers outlining temporary expansion of Medicaid coverage for telehealth services that includes chronic disease management and behavioral health services.

The impact of COVID-19 on public health, state budgets, health care delivery systems, and CYSHCN and their families that these systems serve, will last much longer than the pandemic itself. State Medicaid, public health, mental health, and other state agencies that serve CYSHCN and their families are currently experiencing an overload on their programs, infrastructure and workforce. They also face new policy questions that had not been necessarily considered prior to the pandemic and challenges to their public health and health care coverage systems that are unprecedented in recent history. NASHP staff will continue to report on state strategies that assure access to health care services for CYSHCN and their families. Questions that will be considered include:

  • How are changes in federal and state policies helping children and adults with chronic and complex health care conditions maintain access to and continuity of care during the COVID-19 pandemic?
  • What other policy changes are states considering, and is additional federal guidance needed to further support state efforts?
  • Should policies enacted to ensure access to services during the pandemic be extended beyond the emergency period?
  • What impact do temporary policy changes have on the ability of states to measure quality of care for children and adults with chronic and complex conditions in the short- and long-term?
  • What are the budget implications of these types of changes to state policies?
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