Updated May 7, 2020
In the past two months, 35 states* have rapidly amended their Medicaid home- and community-based services for older adults and their family caregivers to ensure access to long-term services and supports during the COVID-19 crisis. Under new federal rules, the states applied for Medicaid 1915(c) Appendix K waivers to make temporary or emergency-specific changes to protect enrollees.
Most of the states have also received approval for home- and community-based services waivers targeting other populations, such as children and people with intellectual/developmental disabilities. Of these 35 states, 19 (AK, AR, CO, DC, GA, IA, KS, KY, MA, MD, MN, MO, NM, NV, OR, SC, UT, VA, and WY) have Appendix K combination waivers that allow them to modify many waiver programs with one Appendix K application.
A Landscape of Flexibility
Overall, states are incorporating flexibilities to help Medicaid enrollees with long-term needs receive services, and some states have included flexibilities to help enrollees remain on the waivers during the emergency period. The major policy changes affect the following:
Telehealth: Nearly all of these states permit added flexibility for services, such as telehealth, or allowing services to be provided in alternative settings, such as private homes. To cut down on outsiders from entering family homes, many states are allowing for electronic and telephonic case management, service planning, evaluations, and monitoring, as well as electronic signatures or verbal approval to avoid face-to-face meetings.
Family caregiver supports: States often rely on family caregivers to provide home and community-based services to Medicaid enrollees. Recognizing this, some of these new COVID-19-related flexibilities directly assist family caregivers. Several states (AK, AZ, CA, CO, CT, DC, FL, GA, IA, KS, MS, NM, NC, ND, OK, SD, UT, and WV) are allowing family caregivers to provide services and, in some states, receive reimbursement when the hired aide is not available.
Meals and other services: To provide added support, many states (such as AZ, CO, CT, IA, KS, KY, LA, MA, MS, NC, ND, OK, SC, and UT) are expanding home-delivered meals. Several of these states (including AZ, CT, IA, MA, MS, SC, and UT) are allowing for non-traditional providers to provide the meals.
Providers: Many states are relaxing provider qualifications, including training, certification, and recertification requirements, to incorporate new, current, returning, or out-of-state providers. Several states also allow for flexibility on certain types of background checks, or qualifying relatives/family members to be direct care workers pending background checks. States (such as AK, AR, CO, DC, GA, KY, LA, MA, MS, NE, ND, OR, UT, and WA) allow for temporary payment rate increases for some providers to ensure continuity of services. Additionally, many states (such as AK, AZ, CO, DC, FL, GA, IA, KY, LA, MT, NM, NC, NY, OK, OR, UT, VA, PA, and WA) allow for retainer payments if a Medicaid enrollee or provider is not available because of COVID-19. These states often limit the payment to no more than a certain number of consecutive days, for example, 30 days.
Reporting: A number of states are loosening reporting requirements. For example, Kansas has requested a nine-month extension for its waiver reports and Oklahoma requested flexibility on its audit requirements.
State Medicaid programs have great flexibility in what services they provide and how they fund them, especially during the pandemic. For example, states can tap the temporary 6.2 percentage federal matching increase that was recently enacted in response to COVID-19. These Appendix Ks are an important tool for states because home- and community-based services waivers are serving people in the community who meet the level of care needs for services in nursing homes.
These policy changes are temporary, only lasting during the pandemic. After the COVID-19 crisis, it will be important to better understand the impact of these policy changes (telehealth, family caregiver supports, meals, provider flexibilities, and the ease of reporting) on cost and quality of life and determine if some of these changes should continue after the public health crisis abates.
The National Academy for State Health Policy (NASHP) developed an interactive map of state Appendix K waivers and will continue to update this information as more states make these modifications. In addition, NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living, published a report and interactive map on Medicaid information, training, and counseling resources for family caregivers.
*As of May 7, 2020, the 35 states that modified their aging and disability waivers were Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Utah, Virginia, Washington State, Washington, DC, West Virginia, and Wyoming.