Hospitals and health care providers need financial support to respond to the pandemic and for future viability. In response, Congress allocated billions of dollars in relief funds through multiple existing and new programs. The disbursement of these funds is uncoordinated and so are public reports that track where the money is going, but states need to know how much these health care systems are getting.
As states loosen restrictions on stay-at-home orders, many are struggling to establish clear and consistent COVID-19 testing protocols to support individuals’ safe return to work and school and identify ways to pay for increased testing. Absent federal guidance, there is significant debate about who is responsible for funding testing – insurers argue a test must be medically necessary and employers already hard hit by shutdowns contend that paying for testing is a public health obligation.
Multiple federal programs have recently emerged that fund testing, but to date, they primarily cover only the uninsured and there is no clear roadmap for how these fragmented funding streams interrelate and how states should respond. One small piece of the solution appears to rest in state Medicaid programs.
Under the Families First Coronavirus Response Act (FFCRA), states can enroll qualifying uninsured individuals in a new Medicaid eligibility category that covers diagnostic testing and testing-related services, as well as antibody tests. The option is available from March 18, 2020 (when the law was enacted) through the end of the public health emergency period, and states that have chosen this option receive a 100 percent funding match for the new group.
While there is no income limit for individuals to be eligible for the new Medicaid COVID-19 testing group, individuals must meet other qualifying criteria:
- Individuals must be uninsured – not enrolled in private market coverage or in other federal health programs such as Medicare or a mandatory Medicaid eligibility group, with the following stipulations:
- Individuals who are enrolled in short-term limited duration plans are considered to be uninsured for purposes of eligibility for this new group.
- Individuals who live in states that have not implemented the Affordable Care Act’s (ACA) Medicaid expansion but who would have been eligible for the ACA expansion group are eligible for coverage through the COVID-19 testing group if they have no other health coverage.
- Individuals who are enrolled in Medicaid coverage that offers a limited benefit package (e.g., coverage for tuberculosis, family planning-only services, or individuals who qualify as medically needy) are also eligible for the new Medicaid coverage option.
- Individuals must be state residents, provide proof of US citizenship or of a qualifying immigration status, and a Social Security number.
With limited federal guidance available initially – until recent guidance was issued earlier this month – states that chose to implement the option had to take the initiative in determining how to operationalize their enrollment processes for the new eligibility group. States have taken different implementation approaches, depending on the structure of their eligibility determination systems and procedures.
How States Are Implementing the New Medicaid Option
Connecticut opted to build off of its existing eligibility determination processes, and the state now conducts a full assessment of Medicaid eligibility of uninsured individuals seeking coverage for COVID-19 testing. Individuals apply through the state’s Access Health CT portal, which allows for a real-time eligibility determination. While using the complete eligibility determination process results in individuals who are potentially eligible for the COVID-19 testing group receiving notices indicating they are ineligible for Medicaid, the state has developed tailored messaging that informs these individuals that they will be assessed for eligibility for the COVID-19 testing group. State agency staff then use a manual process to evaluate whether these individuals qualify for the testing group. The state also looked back at applications filed since March 18 to identify other potentially eligible individuals and enroll them in the option. Despite requiring additional staff work, this manual part of the process has been fairly manageable because current enrollment is relatively low — about 600 individuals have been enrolled into the new group since the launch of the initiative in early May. In addition to information on the state’s website, state officials have actively publicized the option through provider bulletins, press releases, and outreach to a wide range of stakeholders.
In anticipation of a potential influx of applicants, New Mexico chose to assign the applications for the testing group to a separate unit of eligibility determination workers to prevent regular Medicaid application offices from becoming overburdened. The state created a simplified application for individuals applying for the COVID-19 testing group, and has also developed a memo outlining how providers can bill Medicaid for eligible individuals. To help expedite the establishment of the program, the state chose to use an existing eligibility category code that was already programmed into the state’s system. During the current initial implementation phase, most of the applications have been paper-based. State officials are in the process of developing a mobile-enabled online application to allow individuals to fill out the form on their phones when they are waiting in their cars at testing sites.
In Utah, state officials report they are developing a hybrid eligibility determination process for the new group that will allow for both paper-based and online applications. When the coverage option launched on June 1, 2020, the state began accepting applications through its presumptive eligibility portal tool, which allows for a simplified and streamlined process and a full Medicaid eligibility determination. Individuals will also soon have the option to use a simplified paper application to apply, and the state also identifies potentially eligible individuals from its general pool of denied Medicaid applications. Utah officials are in the process of working with testing sites to enable automatic loading of multiple applications simultaneously into the state’s system. Also, like New Mexico, the state is developing ways for individuals to easily apply for coverage in real time when they are at testing locations.
Multiple, Uncoordinated Sources of Federal Funds Support Testing for Uninsured
A complicating factor for states deciding whether to implement the new Medicaid coverage group is that there are other pools of federal funding for COVID-19 testing, but it is unclear how they are all intended to interact. The COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program reimburses providers for COVID-19 testing and treatment claims for uninsured individuals starting on Feb. 4, 2020. Specifically, the program’s FFCRA relief fund contains $2 billion for provider reimbursement for COVID-19 testing of uninsured individuals. Providers are able to submit claims through a portal managed by the Health Resources and Services Administration (HRSA) in order to receive reimbursement equal to Medicare rates. Unlike the Medicaid option, proof of citizenship or a qualifying immigration status is not required. Additionally, the Paycheck Protection Program and Health Care Enhancement Act also established a $25 billion COVID-19 testing fund, of which $1 billion must be used to cover COVID-19 testing for uninsured individuals (this $1 billion was added to the FFCRA Relief Fund, bringing the total of that fund to $2 billion).
Some states have opted not to implement the Medicaid COVID-19 testing group — including Washington State, which already has an approved state plan amendment to do so — because of the availability of reimbursement through the HRSA-administered fund, as well as anticipated operational challenges involved with implementing the Medicaid option. Some of these issues are related to potentially needing to make complex systems changes or complications with the application process, such as obtaining third-party signatures or conducting manual entry of applicants’ data. Another barrier is the potential additional burden on eligibility determination workers overall, who already may be managing a greater number of applications in states where Medicaid enrollment is beginning to increase.
Another consideration for states deciding whether to take up the Medicaid coverage option is that it is unclear how long the HRSA-administered funding will last. This concern about the finite funding through the HRSA portal is cited on Utah’s state webpage as one of the key reasons the state chose to implement the Medicaid testing eligibility group. Other states, such as Connecticut, began efforts to implement the Medicaid coverage option prior to the availability of the HRSA funds. In New Mexico, officials indicated they are not prescriptive in instructing providers how to submit claims for COVID-19 testing and recognize that providers may choose to utilize the HRSA reimbursement process instead of the Medicaid coverage option, particularly because some of the HRSA funding also covers the cost of COVID-19 treatment.
Currently, some states that have implemented the new Medicaid eligibility group are weighing whether to invest more resources to automate enrollment processes for these applicants, but may be hesitant to do so because the coverage category is temporary. While this new Medicaid eligibility group will no longer exist after the end of the public health emergency period, the need for COVID-19 testing of uninsured individuals will remain a pressing issue for the foreseeable future. State officials continue to emphasize the need for greater federal-level recognition and support of states’ testing needs, including testing of asymptomatic individuals, beyond the emergency period and across all health coverage programs.
|Key Federal Funding Sources for COVID-19 Testing and Treatment
|Families First Coronavirus Response Act (FFCRA)
|New optional Medicaid eligibility group provides coverage of COVID-19 testing for uninsured individuals||States receive 100% federal medical assistance percentage (FMAP) for testing and testing-related services for enrolled individuals and related administrative costs|
|FFCRA Relief Fund||$1 billion to reimburse providers for testing and testing-related services for uninsured individuals|
|Coronavirus Aid, Relief, and Economic Security (CARES) Act
|Provider Relief Fund||$100 billion, primarily to compensate providers for lost patient revenue, but an unspecified amount of the fund is available to reimburse providers for COVID-19 treatment|
|Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA)
|Additional funding for Provider Relief Fund||$75 billion in additional funding, bringing Provider Relief Fund to $175 billion|
|Funding for COVID-19 testing||$25 billion – $11 billion for state, local, and tribal governments and $1 billion added to FFCRA Relief Fund to cover testing for uninsured individuals|
As recent data shows, COVID-19’s infection and death rates illustrate the profound racial and ethnic disparities in the nation’s health care system and the social and economic inequalities that affect health outcomes. To curb COVID-19 and improve the quality of care delivered to communities that have faced decades of discrimination, a few states are bolstering their community health workforces.
Community health workers (CHWs), are culturally competent, frontline public health workers who are trusted by the communities they serve. Evidence suggests individuals benefit from relationships with people who have similar lived experiences and are members of their community. CHWs are uniquely positioned to build trust and address barriers that traditionally underserved communities face when seeking medical care and services. CHWs can also provide collaborative, patient-centered approaches to care and generate cost savings for state programs.
History of State CHW Initiatives
Before the pandemic, many state programs enlisted CHWs to address challenging aspects of their health improvement initiatives, such as facilitating care coordination, enhancing access to community-based services, and addressing social determinants of health. Payment strategies for CHWs vary; a majority of services are grant-funded with some states reimbursing for CHW services through their Medicaid programs or hiring CHWs as part of managed care organizations.
As states work to address COVID-19, they are bolstering their health care workforces, ramping up contact tracing programs, and finding new ways to fill the gaps in the public health infrastructure created by chronic underfunding. With increased recognition of the adverse health impacts of structural racism, CHWs — who were deemed essential critical infrastructure workers” by the Department of Homeland Security — may strengthen the emergency response and facilitate recovery across demographics.
State Examples of CHW Engagement to Address COVID-19
- Delaware: In May, Gov. John Carney announced a partnership with Healthy Communities Delaware — a collaboration between the Delaware Division of Public Health, the Delaware Community Foundation, and the University of Delaware. The partnership’s goal is to provide linkages between those who test positive for COVID-19 and CHWs, who can help coordinate basic needs like grocery delivery and housing during a period of quarantine. Healthy Communities Delaware is coordinating the effort in partnership with community-based organizations.
- Hawaii: The University of Hawaii is partnering with the Hawaii Department of Health to expand the CHW curriculum at community colleges so that graduating CHWs are equipped to assist with COVID-19 contact tracing efforts. CHWs will specifically help with contact tracing efforts in Native Hawaiian/Pacific Islander communities, which are disproportionately affected by COVID-19, and among individuals facing homelessness and unemployment.. The funding for this initiative was appropriated from Hawaii’s federal CARES Act relief funds.
- Massachusetts: The Office of Community Health Workers recently issued guidance for CHW employers detailing how they can engage CHWs in the state’s COVID-19 pandemic response. The suggestions include cultural competence training and outreach about the virus and its impacts, connecting individuals with community services and supports, and assisting people with the new technologies needed for telehealth appointments. The guidance also acknowledges the increased need for resources, technology, and employer support as CHWs take on a growing and varied number of challenges presented by the pandemic.
Some cities also present promising examples of how CHWs can factor into response and recovery plans. The City of Baltimore is responding to COVID-19’s dual economic and public health crises by creating the Baltimore Health Corps. The pilot program, funded by the CARES Act, the Baltimore City Health Department, the Mayor’s Office of Employment Development, and The Rockefeller Foundation, will hire and train individuals who have recently lost their jobs due to the pandemic to be contact tracers and CHWs. The Health Corps will primarily serve communities that have been disproportionately impacted by COVID-19.
The examples above spotlight how partnerships between different sectors allow cities and states to address the needs of specific populations, to create jobs, and to ramp up their contact tracing workforces. Each addresses the need for equitable care that is delivered by people who understand the lives and challenges of the community they are serving in order to make sure interventions are appropriate and effective. States may want to consider adopting similar strategies along with training their existing CHW workforces for the new challenges of COVID-19 response and recovery.
Contact tracing, a strategy long-used to contain the spread of infectious diseases by identifying and isolating people exposed to an infection, has become a crucial state tool to curb COVID-19. But the pandemic requires significant ramping up of contact tracing capacity and funding. Experts estimate 30 contact tracers are needed for every 100,000 Americans – a total of 98,460 workers nationwide – far short of states’ current tracer workforces.
As the death toll in nursing homes rises and COVID-19 testing capacity slowly expands, states are each crafting new testing policies to prevent and contain outbreaks in long-term care facilities, where more than half of coronavirus deaths have occurred in many states.
While the US Centers for Disease Control and Prevention (CDC) has issued general recommendations for testing nursing homes’ staff and 1.3 million residents, governors are issuing executive orders with precise testing mandates that include deadlines and penalties for noncompliance, including loss of operating licenses if nursing homes do not meet testing requirements.
On May 19, 2020, the CDC updated its general principles guiding nursing home testing and recommended that all facilities perform a universal, baseline COVID-19 test in residents and staff based on their available “resources and goals” when at least one infection occurs. Nursing homes should then test all residents weekly until all residents test negative. Before a nursing home can reopen to visitors, the federal government recommends daily screenings of staff (taking temperatures and asking about symptoms) and weekly testing of all staff.
States Issue their Own Testing Guidelines
Faced with COVID-19 nursing home deaths, states are mandating specific testing strategies – in some cases stricter than the federal government’s recommendations – though many states still struggle with limited tests and personal protective equipment (PPE) supplies.
New York: Because asymptomatic facility staff are believed to introduce many coronavirus infections into nursing homes, New York Gov. Andrew Cuomo issued an executive order mandating twice-weekly testing of the state’s 185,000 nursing home staff, in addition to the blanket, baseline testing of nursing home staff and residents after an infection. The facilities must arrange for the testing – though employees can use free state testing sites – and report results to the state or risk losing their operating licenses.
New Jersey: New Jersey’s health commissioner signed an executive directive that requires all long-term care facilities, including nursing homes, assisted living residences, comprehensive personal care homes, residential health care facilities, or dementia care homes to provide COVID-19 baseline testing of all staff and residents by May 26, 2020. Those who test negative must be retested within three to seven days after the baseline testing, and any additional testing should follow CDC’s guidelines on Testing for Coronavirus in Nursing Homes. Failure to comply with the guidelines could result in loss of a facility’s operating license.
Maine recently tripled its test kit supply after it purchased $750,000 worth of tests, using federal relief funds, from Maine-based IDEXX, a veterinary biomedical company that repurposed to produce COVID-19 tests. Maine’s testing capacity increased from 2,300 a week to more than 7,000. Before the IDEXX supply became available, facility-wide testing in nursing homes occurred only if there were a minimum of three reported COVID-19 cases in the nursing home. Nirav D. Shah, director of Maine’s CDC, told NASHP the increased testing capacity now allows testing of all nursing home staff or residents after one individual tests positive. When asked about conducting blanket, pre-emptive universal testing in all Maine nursing homes, he explained, “Maine is reviewing that type of expanded testing protocol, but based on input from medical directors at congregate care facilities, an approach that focuses on staff or some other form of targeted testing is under review.”
West Virginia: In April, Gov. Jim Justice issued an executive order, directing the West Virginia Department of Health and Human Resources and the West Virginia National Guard to “immediately” test every nursing home resident and staff member throughout the state. His order places the onus on state and national guard officials – not nursing homes – to perform the tests. Residents and staff members who have previously been tested will be retested to ensure the most up-to-date results possible.
Pennsylvania: Two weeks ago, Gov. Tom Wolf recommended all nursing home employees, patients, and clients at facilities that have had reported cases to be tested once a week for COVID-19. At facilities that have not had reported any cases, Wolf recommended facilities consider testing 20 percent of staff and residents weekly.
Maryland: Gov. Larry Hogan ordered all Maryland nursing home residents and staff to be tested for the coronavirus by state “strike teams” regardless of whether or not they have exhibited any symptoms of the virus. An earlier order had mandated testing in only symptomatic workers and residents. Nursing homes will be prioritized based on an imminent outbreak or a current rising threat of an outbreak. The order also requires nursing homes to have a physician, nurse practitioner, physician’s assistant or registered nurse evaluate all residents on a daily basis. Failure to comply is a misdemeanor punishable by one-year imprisonment and/or a $5,000 fine.
In Washington State, where 61 percent of COVID-19 deaths have occurred in nursing homes, Gov. Jay Inslee ordered widespread testing at all skilled nursing facilities across the state and tasked the Department of Health to come up with a plan to test every nursing home resident and staff member regularly. That will require 37,000 tests, officials report, which doubles the number of tests currently required.
Florida: Earlier this month, Florida’s health department issued an order requiring all nursing home staff and residents to be tested for COVID-19 when there has ben a reported COVID-19 case in the facility. This order specifically included nursing home staff who are not in the building at the time of the baseline screening — otherwise the facility faces fines or risks having its license revoked. The order, issued by Florida’s Agency for Health Care Administration, requires the state’s 3,800 facilities to make all staff and residents – including asymptomatic staff, some of whom have refused to be tested for fear they would lose their jobs – available for testing by the Florida Department of Health and the National Guard. Officials in Florida say a shortage of test kits continues to deter testing at facilities that do not have reported cases, despite CDC guidelines.
Texas faces a similar problem. Gov. Greg Abbott recently ordered health officials to conduct universal testing in all nursing homes, mirroring CDC guidelines, and enlisted state and local public health officials, including local fire department staff, to perform testing. Because of staffing and testing limitations, officials from the Texas Health and Human Services Commission said they do not know when testing will be completed. As of last week, universal testing had occurred in about 190 of 1,224 licensed nursing facilities, according to a Texas Department of Health and Human Services statement. “At this time, cost estimates are still being calculated, and it’s expected costs will be reimbursable by the federal government,” according to the statement. “The state will be working with nursing facilities and officials around the state to assist with capturing costs and ensuring they are able to seek reimbursement.”
Universal Nursing Home Testing Is a First Step
As states struggle to confront the pandemic’s death toll in their nursing homes, leaders acknowledge that persistent test and PPE shortages are hindering their efforts, and a one-time, universal testing, funded in large part by federal relief funds, offers a first step toward controlling a pandemic that they are only beginning to understand.
Utah, which is currently working to test all nursing home staff in compliance with CDC recommendations, exemplifies what many states face. In the Utah Targeted Recommendations in Support of Long-Term Care Facilities during the COVID-19 Pandemic report to the governor, released May 18, 2020, health experts point out that there continues to be delays and significant under-testing in rural nursing homes. “Some (nursing home facilities) are electing not to engage in widespread testing, leading to under-reporting and this has contributed to the undetected spread of the disease in some facilities,” the report’s authors wrote. The task force recommends Utah:
- Require and provide testing kits, PPE, and staff to prioritize comprehensive, widespread and frequent testing of direct care staff and nursing home residents;
- Provide comprehensive contact tracing of all positive nursing home cases;
- Prioritize antibody testing for nursing home staff as it becomes available; and
- Prioritize rapid COVID-19 testing for nursing home staff as it becomes available.
As states face reduced tax revenue and inevitable shortfalls due to economic fallout from COVID-19, officials question if there will be additional federal relief funds forthcoming to cover future testing needs.
- The current baseline tests capture a snapshot of COVID-19 infections in a nursing home facility at one point in time, but a minimum of weekly testing of staff has been recommended moving forward.
- Additionally, nursing homes make up less than half of congregate care facilities in many areas. As states address the nursing facility risk through universal testing, many are developing similar testing strategies for other congregate settings.
“A failure to aggressively address these issues now could result in high costs related to COVID-19 treatment and management, and long-term care facilities could become a reservoir of SARS COV-2 which could accelerate a second wave of the pandemic,” Utah’s task force members warned in their report.
Confronted with a shortage of test kits, rising COVID-19 cases, and pressure to reopen, many states are designing innovative contact tracing initiatives that use private and public health expertise, volunteers, and traditional phone calls to reach individuals who have been exposed to the coronavirus so they can self-isolate to stop the spread of infection.