More than a dozen states have recently submitted 1115 waiver applications that have the potential to safeguard access to care and increase support for children during the COVID-19 pandemic.
If approved, these 1115 waivers would be retroactively to March 1, 2020, and expire “no later than 60 days after the end of the public health emergency.” The Centers for Medicare & Medicaid Services (CMS) created an 1115 waiver template for states to use when requesting authority to address the impact of COVID-19 on their Medicaid programs. The National Academy for State Health Policy (NASHP) April 6, 2020, blog, State Medicaid Strategies to Maintain Access to Care for Children with Special Health Care Needs during the Pandemic, outlines steps states are taking to support children with special health care needs using 1135 and 1915(c) Appendix K emergency waiver authorities.
Of the COVID-related 1115 waiver applications reviewed by NASHP, several contain provisions related to children. The 1115 waiver provisions listed below represent a selection of key strategies for serving children during the COVID-19 pandemic that other states may want to consider for their Medicaid programs, including payments to foster caregivers, reimbursement of family caregivers, and telephonic and virtual care coordination services.
Payments to foster caregivers: Children in foster care are more likely to experience physical and mental health challenges compared to children in the general population. During the COVID-19 pandemic, children in foster care may not be able to access their typical support services through schools and specialty physical and mental health providers. Arkansas, for example, is acknowledging the importance of providing stability and support to these vulnerable children by requesting authority through a 1115 waiver, to provide an additional monthly payment to all foster caregivers (“licensed foster parents, relative caregivers, and fictive kin”) for providing at-home care for children in their care. These monthly payments would be designed to “prevent negative impacts to physical and mental health during emergency period.”
Reimbursement for family caregivers: Both Georgia and New Hampshire have included provisions in their 1115 COVID-19 waiver requests asking for Medicaid reimbursement of family caregivers for caring for youth with special health care needs. Georgia’s 1115 waiver request would add a family caregiver service to its Georgia Pediatric Program in the event that licensed professional nurses (LPNs) are not available to provide the child’s needed services. New Hampshire’s 1115 waiver request asks to waive CFR 440.167 and allow family members to perform and be reimbursed for personal care services. Both of these approaches allow children who receive services in their homes to remain in a home setting and potentially reduce the need for hospital or nursing facility placement during a time when these facilities are being overwhelmed with COVID-19 patients.
Care coordination through telehealth for Medicaid managed care organizations (MCOs): Care coordination services are critical for children with special health care needs and are important services to improve health outcomes, reduce caregiver and patient burden, decrease health care costs, and strengthen systems of care for children with chronic and complex conditions. Currently, New Mexico’s Medicaid MCOs are required to conduct many care coordination activities (including initial screenings, needs assessments, and nursing facility level of care determinations) via home visits involving face-to-face interactions. As a result of COVID-19, New Mexico is requesting in its 1115 waiver application to allow its MCOs to continue to conduct their care coordination supports virtually – by telephone or, if possible, using video technology. This provision may help ensure that these valuable supports and services are continued and that children and youth with special health care needs (CYSHCN), in particular, are maintaining access to their care coordinators and care coordination services.
The National Academy for State Health Policy will continue to closely follow CMS responses to these waiver submissions and track any additional state 1115 waiver actions in response to the COVID-19 pandemic.
As states look for ways to ensure their systems are designed to support children during the pandemic, especially those with special health care needs, the National Standards for Systems of Care for CYSHCN can be a helpful resource. The standards address the core components of the structure and process of an effective system of care for CYSHCN such as access to care, eligibility and enrollment, and care coordination.
Many state waiver proposals during the pandemic are designed to improve aspects of the health care delivery system that are addressed by the National Standards, such as acknowledging the critical role families play in caring for children and children with special health care needs and allowing for flexibility in how care coordination is provided to best meet the needs of families and children. The standards can provide states with a framework to help ensure that key provisions and health care system components and protections are maintained during a time of disruption in the traditional health care delivery system.