Through a unique partnership between the Iowa Medicaid and public health agencies, Iowa’s I-Smile program addresses the disproportionate impact of dental disease on low-income individuals. I-Smile and its related I-Smile @ School for children and I-Smile Silver for adults help promote preventive oral health services and reduce barriers to dental care across the state.
In children, dental caries is the most common chronic disease, affecting 60 percent of individuals ages 5 to 17. Additionally, studies indicate that up to 40 percent of pregnant women experience periodontal disease, and 25 percent of adults over age 65 lack their natural teeth. Additionally, significant disparities exist. In 2016, Medicaid recipients accounted for more than half of dental-related emergency room visits, and in 2019, 44 percent of low-income adults had untreated tooth decay.
Dental disease not only adversely affects oral health, but is also associated with diabetes, heart disease, stroke, and low birth weight and preterm births. Fortunately, preventive oral health care, including sealant and fluoride treatments, can save money and lives. While many states are expecting budget cuts in response to COVID-19-related revenue declines, increasing access to preventive dental care through programs like Iowa’s I-Smile may minimize long-term dental and overall health costs by effectively reaching underserved populations.
In May of 2005, Iowa passed the IowaCare Medicaid Reform Act, which includes the provision that every child age 12 and younger enrolled in Medicaid must have a designated dental home. In addition, the legislature sought to ensure that children are provided with the dental screenings and preventive care identified as part of the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program’s oral health standards. I-Smile was created in response to this 2005 legislation and funded via a Memorandum of Understanding (MOU) between the Iowa Department of Human Services (IDHS) and the Iowa Department of Public Health (IDPH).* IDPH holds the majority of the responsibility under the MOU and contracts with local Title V agencies (public or private non-profit organizations), that administer I-Smile and ensure access to oral health services for children and pregnant women across the state.
Oral Health in Iowa at a Glance:
- In 2002, Medicaid reimbursement for preventive oral health services became the standard of care for dental screening centers in Iowa.
- In 2018, $22 million of a total $31 million spent on preventable dental surgeries for children ages 5 and younger was billed to Medicaid.
- In 2019, 73 percent more Medicaid-enrolled children in Iowa saw a dentist than in 2005.
- In 2018, 50 percent of Medicaid-enrolled children received a dental service, including two out of every three children ages 3 to 12. Iowa rates surpassed both the national average of 34.6 percent of low-income children receiving preventive dental care, as well as the Healthy People 2020 goal of 33.2 percent.
- In 2018, more than 30,650 children received preventive dental care in public health locations, including Women, Infants, and Children (WIC) clinics, schools, and Head Start centers. This number is almost four-times as many as in 2005.
- Medicaid costs per child (ages 0-12) per year have remained relatively steady since the start of the program in 2005. After accounting for inflation and a 1 percent rate increase in 2014, the average cost was $150.75 in 2005 and $170.74 in 2019.
- Iowa met the Healthy People 2020 goal to reduce the proportion of adults 65-74 years old that have lost all of their teeth; in 2014, 13 percent of Iowa adults ages 65-74 years were without their natural teeth, well under the goal of 21.6 percent.
*The MOU for I-Smile does not include I-Smile @ School and I-Smile Silver.
I-Smile in Practice
I-Smile’s mission is to connect Iowa children with “dental, medical and community resources to ensure a lifetime of health and wellness.” I-Smile primarily targets the 47 percent of Iowa children ages 0-12 who are enrolled in Medicaid in order to provide dental care and disease detection early in life and limit costly, preventable dental procedures. Additionally, given the link between mothers’ oral health and their infants’, I-Smile also serves pregnant women.
Twenty-three I-Smile coordinators are responsible for implementing I-Smile strategies within all 99 Iowa counties by serving as a point of contact with the dental network. I-Smile coordinators work with families, dentists, medical professionals, schools, businesses, and local non-profits to assess community needs, coordinate dental care, improve oral health literacy and reduce barriers to care. I-Smile uses multiple approaches to improve dental care, including:
- Partnering with WIC clinics, schools, Head Start centers, preschools, and child-care centers to provide dental screenings and fluoride application;
- Coordinating dental appointments, including scheduling, setting up transportation assistance, and helping parents find payment sources for dental care;
- Training medical professionals to administer fluoride varnish and screen for dental disease; and
- Educating community members about the importance of oral health through public events, health fairs, and online informational tools.
I-Smile @ School
I-Smile @ School is a division of I-Smile that helps children access dental care by providing dental screenings, sealants, fluoride varnish, and oral health education in elementary and middle schools during the school day. I-Smile @ School strategies include:
- Assessing oral health needs of schoolchildren;
- Developing networks with dental offices; and
- Providing oral health education, preventive dental services, and care coordination.
I-Smile @ School is administered by 19 Title V agencies across the state. Funding sources include the Title V block grant, Medicaid reimbursement, a Centers for Disease Control and Prevention grant, and the Delta Dental of Iowa Foundation. Schools must have a minimum of 40 percent of students on free or reduced lunch plans to participate in the program. In the 2018-2019 school year, 43.4 percent of children who received a dental sealant through I-Smile @ School were enrolled in Medicaid, and an additional 9.8 percent had no dental insurance.
I-Smile @ School’s goals align with the Healthy People 2020 and Healthy Iowans 2017-2021 objectives, which include increasing dental sealants and preventive dental services for children and reducing untreated dental decay. In its Strategic Plan for 2018-2023, the program identified three outcome measures:
- Increase the number of schools served from 63 to 74 percent;
- Provide sealants to 5 percent more children; and
- Increase the sealant program consent return rate from 42 to 52 percent.
The strategic plan also identified a number of focus areas, including building cross-agency partnerships, implementing a state system for data collection, creating a communication plan for disseminating oral health information, and improving I-Smile @ School’s infrastructure.
Iowa is one of 19 states (including Washington, DC) in which Medicaid covers extensive adult dental benefits. Through Iowa’s Dental Wellness Plan, Medicaid enrollees ages 19 and older can access full benefits, provided they complete “Healthy Behaviors” annually, which include an oral health self-assessment and preventive services. Despite this, adults, and especially senior citizens, report widespread barriers to care and low utilization rates. In 2016, 38 percent of Iowa seniors had not seen a dentist in five years, and 53 percent reported they could not afford dental care.
|In Iowa, full adult dental benefits cover the following:
Diagnostic and preventive dental services
Fillings for cavities
Surgical and nonsurgical gum treatment
Dentures and crowns
I-Smile Silver is a pilot program implemented across 10 Iowa counties designed to help adults ages 21 and older access dental care. I-Smile Silver is administered by the Iowa Department of Public Health using funding from the Delta Dental of Iowa Foundation and a Health Resources and Services Administration grant. The pilot project began in November 2014. IDPH contracts with three county health departments (covering 10 counties) to conduct the project. Each contractor has a dental hygienist as the local I-Smile Silver coordinator who is responsible for implementing strategies that include:
- Assessing needs and assets related to oral health;
- Providing training for medical providers, direct care staff, and home care providers;
- Creating referral networks with dental and medical offices to address oral health needs;
- Working with hospitals and health systems to address oral health related to chronic disease;
- Promoting oral health through participation in community events and distribution of materials; and
- Providing care coordination and preventive dental services.
In 2017, the IDPH conducted its first screening survey of older adults’ oral health. The project will continue to grow over the next two years, with the hope that its importance will be recognized and the program will receive funding to allow for statewide expansion of the pilot.
- Through an MOU, states can create cross-sector partnerships in order to fund oral health initiatives and create clear implementation responsibilities across agencies.
- States can effectively reach low-income children and pregnant women by partnering with local organizations to provide dental services and oral health education, including leveraging Title V agencies and schools.
- Providing strong care coordination services is a critical tool for helping individuals access preventive dental care.
Challenges and Next Steps
While Iowa continues to make strides in increasing access to dental and oral health care, particularly among Medicaid-eligible children, some challenges remain. Compared to 60 percent of children ages 3-12, only one in five Medicaid-enrolled children under age 2 saw a dentist in 2019. To increase these numbers, I-Smile started the Cavity Free Iowa campaign to train pediatricians to provide preventive oral health care, including fluoride varnish applications, and education on the importance of oral health.
Additionally, though the number of children on Medicaid is increasing, Iowa is experiencing a decline in dentists who accept Medicaid. Providers note that Medicaid has lower reimbursement rates than private insurance, and often comes with additional administrative burdens.
Finally, as the COVID-19 public health emergency continues to unfold and dental offices address the pandemic’s effects, the long-term impact on oral health care remains unknown. Especially for children who receive dental services through school-based programs such as I-Smile @ School, the pandemic raises concerns about children’s ability to continue to be screened and treated should schools remain closed in the fall. Moreover, older citizens, who are at increased risk for COVID-19, may not feel comfortable leaving their houses to go to the dentist.
To address some of these concerns, Iowa is working to increase the use of silver diamine fluoride, a preventive treatment that can arrest dental decay. The state anticipates there will be fewer dentists accepting new Medicaid patients in the future, and is therefore emphasizing the importance of preventive oral health now to limit future complications requiring care. Iowa is also looking at new points of contact to reach children and adults. As a result of COVID-19, IDPH is preparing to play a bigger role in the dental delivery system by screening for disease, triaging who needs to be seen within a dental office and collecting diagnostics to send electronically to dentists to complete a telehealth exam. While the pandemic may require I-Smile @ School and I-Smile Silver to revise some of their strategies, in the months and years to come programs like I-Smile will undoubtedly play a crucial role in helping Medicaid-eligible children, pregnant women and adults obtain necessary dental services.
Acknowledgements: The author wishes to thank the state officials in Iowa who graciously shared their experiences and reviewed a draft of this publication. Trish Riley, Neva Kaye, and Carrie Hanlon of NASHP provided helpful guidance and assistance. Finally, thank you to the Health Resources and Services Administration officials who provided thoughtful input.
This project was supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UD3OA22891, National Organizations of State and Local Officials. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US government.
State Medicaid, children’s health insurance programs (CHIP) and health insurance marketplaces strive to prepare for an expected increase in the demand for their services as they navigate a world roiled by COVID-19, an economic downturn and ensuing budget crises, and unpredictable federal relief efforts.
Despite the availability of safe and effective vaccines through Medicaid and the Vaccines for Children program, immunization rates among children enrolled in Medicaid remain lower than for privately-insured children. Disparities in vaccination rates also persist for African-American children and those living in poverty. Nearly half of US pregnant women are covered by Medicaid, but data shows that publicly-insured women have lower immunizations rates than women with private insurance.
These resources showcase effective state efforts to harness Medicaid’s reach to increase immunization rates in these important populations. To suggest a resource or share your state’s immunization efforts, contact Ariella Levisohn.
States Factor in COVID-19’s Impact on Immunizations and VBP Incentives, June 2020. In recent years, a number of state Medicaid programs have instituted value-based payment (VBP) programs to reward managed care organizations for quality care, including achieving high child immunization rates. However, COVID-19 has reduced in-person visits and immunization rates, and this blog examines federal and state guidance and flexibility in VBP incentive calculations to accommodate these declines.
States Establish New Telehealth Policies to Safeguard Well-Child Care and Immunizations, May 2020. COVID-19 has affected children’s access to preventive care across the country; while states’ expanded telehealth policies can increase access to care, in-person visits are still needed for delivery of immunizations and other critical screenings. This blog highlights new state policies on telehealth and well-child visits to ensure children stay healthy during this pandemic and beyond.
State Levers to Improve Immunization Rates: Alabama’s Experience, February 2020. Alabama employs a multifaceted approach to boost immunization rates among its Medicaid, public, and privately covered populations. This NASHP blog details the state’s strategies, including various payment and reimbursement incentives, reporting protocols, and cross-agency partnerships.
Using Data and Innovation, States Work to Improve Maternal Vaccination Rates, November 2019. This NASHP blog examines different strategies California, Colorado, and Wisconsin are using to improve maternal vaccination rates, ranging from including requirements and incentives in Medicaid managed care contracts to using data to identify populations, regions, and providers with low immunization rates.
State Medicaid Levers to Promote Immunization: California’s Experience, September 2019. This NASHP blog highlights strategies California is using to increase childhood immunization rates among Medicaid enrollees, including incentivizing providers, using the state immunization registry to monitor vaccination uptake and requiring managed care organizations to monitor and report on quality measures.
Hawaii Fights the Flu with Pop-up Clinics and State Agency Collaboration, February 2019. This NASHP blog highlights Hawaii’s collaboration between its state education and health departments, which led to “pop-up,” school-based vaccination clinics to increase flu vaccination rates and protect children’s health.
How to Boost Vaccine Rates for Low-Income Families, October 2018. This PEW Charitable Trusts article explores a Community of Practice Immunization project, co-led by the National Academy for State Health Policy, AcademyHealth, and the Colorado Children’s Immunization Project.
State Officials Work to Harness Medicaid as a Change Agent to Increase Immunization Rates, July 2018. This reports on a meeting led by NASHP, AcademyHealth, and the Colorado Children’s Immunization Coalition, which convened state officials and experts to identify strategies to improve immunization rates among Medicaid-enrolled children and pregnant women.
Immunization Community of Practice, February 2018. AcademyHealth and NASHP, with support from the Colorado Children’s Immunization Coalition, worked with state officials interested in improving their immunization rates among low-income children and pregnant women in a Community of Practice. Medicaid agencies worked with public health and Immunization Information System partners to improve policies and outreach to increase immunization rates.
New Program Helps State Medicaid Programs Close an Immunization Disparity Gap, February 2018. This NASHP blog explores how states can improve immunization rates among low-income children by addressing health equity.
State Immunization Strategies to Promote Children’s Preventive Services, last updated September 2016. These maps and 50-state chart illustrate state Medicaid or Children’s Health Insurance Program performance-improvement initiatives that promote children’s preventive services, including immunizations and American Academy of Pediatrics’ Bright Futures recommendations.
Vaccination Coverage Among Children Aged 19–35 Months — United States, 2017, October 2018. This Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Review (MMWR) article highlights current vaccination coverage data and trends.
Vaccine-Preventable Diseases, Immunizations, and MMWR –1961 – 2011, October 2011. This CDC report discusses the history of vaccine-preventable diseases, current global efforts, and the future of immunizations.
Today, a coalition of 20 national organizations representing consumers, health care providers, and health plans sent a letter to Congressional leaders supporting a recent National Governors Association’s request that they increase federal matching funds for Medicaid by 12 percent.
As the COVID-19 public health emergency continues to destabilize the economy, more individuals are turning to their state Medicaid agencies for health coverage. To date, more than 40 million Americans have filed for unemployment benefits in the past 10 weeks, and with job losses many individuals will inevitably lose employer-based health coverage.
Current projections show Medicaid enrollment climbing in the coming months. A recent study conducted by the Kaiser Family Foundation (KFF) estimates that close to 27 million people could lose their employer-sponsored insurance (ESI) due to the economic fallout from COVID-19, and about 12.7 million will be eligible for Medicaid coverage. In a similar study, the Urban Institute projects that 47 percent of individuals who lose ESI would enroll in Medicaid, increasing national enrollment in the program by approximately 11.8 million. Together, these findings show that Medicaid will become the primary source of coverage for individuals who have lost ESI coverage.
While enrollment data from the initial period of the COVID-19 health crisis is not expected to be released by federal officials for several months, local news organizations are reporting preliminary state data that shows some states have already started to experience significant increases in Medicaid enrollment.
- Hawaii’s Medicaid program has received over 21,000 applications since early March, representing an increase of 40 percent from this time last year.
- In April alone, Ohio added 140,000 individuals to its Medicaid program, which brings the percentage of the state’s population covered by Medicaid to 25 percent.
- Michigan and Delaware also experienced significant enrollment spikes, despite declining enrollment during the same period last year, and other states reporting recent enrollment increases include Connecticut, Georgia, New Jersey, New Mexico, Oregon, Pennsylvania, and Virginia.
Some of these enrollment changes could be the result of requirements states must comply with to receive the 6.2 percentage-point increase in the federal medical assistance percentage (FMAP) provided by the Families First Coronavirus Response Act. To receive the increase, states cannot terminate Medicaid coverage during the emergency period for individuals enrolled on or after March 18. However, this likely only accounts for a small portion of the increased enrollment.
While it will take months to understand the full scope of Medicaid enrollment trends during this health and economic crisis, a recent KFF survey found that the vast majority of states with enrollment projections anticipate that enrollee growth this year will far exceed pre-COVID projections for state fiscal year (SFY) 2020 and will continue to rise through SFY 2021.
There could also be an uptick in enrollment in the Children’s Health Insurance Program (CHIP) as families lose ESI and seek coverage options for their children. However, the number of families whose incomes make them eligible for CHIP is not yet known, and some may instead become eligible for Medicaid. Some states have indicated that CHIP enrollment is staying stable or slightly rising because states are opting not to process terminations during the emergency period, while other states have reported significant spikes in CHIP enrollment. Notably, Pennsylvania enrolled 10,200 new children in March and April of this year, increasing its total CHIP population by 5 percent.
Despite these initial reports of increased enrollment over the course of the emergency period, many state officials expect it will take several months before public health coverage programs feel the full effects of the economic crisis. State health officials credit this to several factors, including:
- Grace periods and premium flexibilities that have allowed some employers to maintain coverage for their furloughed and terminated workers;
- Consumer priorities, which are focused on securing immediate needs, such as unemployment benefits and food and housing assistance; and
- Knowledge gaps about where to seek coverage.
To help increase and maintain access to Medicaid and CHIP coverage during the COVID-19 pandemic, many states have elected to pursue flexibilities though disaster relief state plan amendments (SPAs) to ease eligibility determination and cost-sharing requirements and expand opportunities for enrollment. Many states have chosen to waive premiums or copayments, expand presumptive eligibility, and allow for self-attestation of certain eligibility criteria. According to a KFF analysis, 43 states have implemented actions to facilitate access to coverage in Medicaid and CHIP amid the crisis, and the National Academy of State Health Policy (NASHP) is also tracking flexibilities that states have adopted through Medicaid and CHIP SPAs.
State-based health insurance marketplaces have also served as a point of entry for Medicaid coverage for many individuals who have lost employer-based health coverage. Of the 13 state-based marketplaces, 12 have elected to open special enrollment periods (SEPs) for uninsured individuals in the wake of COVID-19. These SEPs have drawn attention to the coverage options that exist outside of employee health plans through advertising campaigns and direct outreach coordinated with states’ labor and unemployment departments. Among the states that that have released enrollment data from their COVID-19 SEPs, Minnesota and Maryland have reported that over 50 percent of individuals who gained coverage through the SEPs were found to be eligible for Medicaid.
As states continue to invest in efforts to enroll a greater number of eligible individuals in Medicaid, they will need to contend with looming budget constraints. In the coming months, states will be challenged with shrinking state revenues and growing costs associated with increased Medicaid enrollment and testing and treatment for COVID-19. It is likely that as emergency protections, such as grace periods for premium payments, for consumers in the commercial market end, more individuals will lose their insurance and may be eligible for publicly subsidized health coverage.
Also, because the increased FMAP is only available through the public health emergency period, an additional concern for states is that it may not be adequate for addressing the long-term economic effects of the outbreak. Governors have already expressed the need for an additional increase to the FMAP and for an extension of this increase through September 2021, but unless Congressional action occurs, states will be facing difficult choices. For many states, budget shortfalls will require significant cuts to Medicaid, leading to new challenges as an unprecedented number of individuals rely on public programs for coverage. NASHP will be continuing to support state officials as they navigate through these complex budgetary, policy, and operational issues.
This infographic highlights what states need to consider when providing pregnancy-related services to Medicaid enrollees through telehealth during the pandemic. Links to more tools and resources are listed below the infographic.
States can use the following flexibilities and tools to increase access to pregnancy-related services via telehealth:
- Medicaid State Plan Disaster Relief State Plan Amendment: States can use these streamlined templates to add telehealth services.
- State Medicaid and CHIP Telehealth Toolkit
- Medicaid and CHIP Telehealth Toolkit Checklist for States
- Section 1135 Waiver Flexibilities: States can use this waiver to waive provider enrollment and prior authorizations requirements to expand access to telehealth services.
- The Office of Civil Rights at the Department of Health and Human Services issued guidance that allows for enforcement discretion for noncompliance with HIPAA regulatory requirements related to providers and telehealth (e.g., using non-HIPAA compliant systems like Zoom).
- Information letters can provide guidance on billing and covered services to managed care organizations.
- NASHP blog: States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment, April, 2020
State Medicaid home- and community-based waivers and state plan amendments can provide critical information, counseling, and training to family caregivers. Recently, the National Academy for State Health Policy (NASHP) reviewed states’ Medicaid 1915(c) and 1115 waivers, and 1915(i) and 1915(j) state plan amendments (SPAs) that focuses on waivers and state plan amendments covering older adults and adults with physical disabilities, to highlight their unique approaches to training and supporting caregivers.
Family caregivers provide increasingly intense and complex care that requires them to learn how to perform difficult medical and nursing tasks. Training and other supportive services offered through Medicaid waivers and state plan options can be important tools to assist the caregivers of Medicaid enrollees with long-term needs, promote better care, and potentially delay admission to higher levels of care. As many individuals are confined to their homes due to the COVID-19 pandemic, reliance on these services and supports provided by family caregivers is greater than ever.
Twenty-four states include education, training and counseling for family caregivers in their 1915c and/or 1115 waivers. Fifteen states use their 1915c waivers to provide these services; six states provide services through a 1115 waiver; and three (Minnesota, South Carolina, and Washington State) include services in both 1915c and 1115 waivers. While states often include these services (particularly within 1915c waivers), states varied greatly in identifying which caregivers were eligible for training, education, and/or counseling services and which services were provided. States also varied in their requirements for how the need for these services was documented.
States define informal or unpaid caregivers using a range of familial relationships. Florida, Rhode Island, and Utah define unpaid caregivers in their states’ waivers as “any person, family member, neighbor, friend, companion, or coworker who provides uncompensated care, training, guidance, companionship or support to a person served.” Georgia is the only state to specify that spouses, in particular, currently are not eligible for specific waiver caregiver education and training services. Georgia and Indiana specified in their waiver service definitions that caregivers had to live with care recipients to qualify as caregivers who could receive specific caregiver education and training services.
Several states make distinctions between paid and unpaid caregivers.
- Seven states (FL, CA, MD, OR, RI, UT, WA) provide education and training services for unpaid caregivers. For example, Washington State’s 1115 waiver includes education and training for unpaid caregivers through its Medicaid Alternative Care (MAC) program, and Rhode Island’s 1115 waiver includes unpaid caregiver training and counseling services.
- Four states (HI, PA, WI, MN) specify that both paid and unpaid caregivers may qualify for specific training services. Hawaii’s 1115 waiver and Pennsylvania’s and Wisconsin’s 1915c waivers specify that paid and unpaid caregivers can access specific services. Minnesota’s 1915c waiver specifies that only consumer-directed community supports services can be used to purchase training for paid or unpaid caregivers. Other waiver services are for informal or family caregivers, and its 1115 waiver mirrored the 1915c waiver.
States’ training and education includes a range of topics and modalities. Collectively, states list a range of different types of training related to medical care, including but not limited to education and training on:
- Specified medical equipment;
- Medical treatment;
- Personal care assistance;
- Performance of instrumental/activities of daily living (I/ADLs) or body movements; and
- Disease pathways or specific conditions.
Eight states (MA, MN, NJ, UT, TN, SC, WA, and WI) listed some kind of formalized training related to providing care. Collectively, states listed various types of services, including evidence-based programs, seminars, group training, or reimbursement for conference attendance. For example, Minnesota allows costs of training and conference registration fees to be included in training and education, but does not cover transportation, travel, meals, or lodging. One state, Maryland, explicitly excludes group or classroom training.
Several states also covered caregiver-specific services, such as:
- Financial support for attending caregiver-related training programs;
- Support groups;
- Non-psychiatric counseling services;
- Caregiver coping skills building; and
- Consultation services.
Hawaii, Iowa, Washington, Minnesota, and New Jersey specifically mention counseling or similar services aimed at caregivers. Iowa’s 1915c waiver includes counseling that could address adjusting to a care recipient’s disability or terminal condition. Two states, New Jersey and Washington State in their 1115 waivers, include training on coping skills as a caregiver support. New Jersey offers seminars, including a seminar on coping skills for caregivers of individuals with long-term care needs. Hawaii includes “supportive counseling” and family therapy in its waiver service list.
States require these services to be included in assessments and care plans.
All states with training, education, and/or counseling services for family caregivers include language in waivers that these services must be listed under a care or support plan, evaluation, service plan, therapeutic regimen, or some other type of identification or assessment in order to be reimbursed. Washington State’s 1115 waiver requires caregivers to complete a specified caregiver screening and, as needed, a specified caregiver assessment to determine qualification for specific tiers of services. Tennessee includes caregivers in its face-to-face assessment – assessing caregiver well-being and continued ability to provide care.
States have great flexibility with Medicaid waivers and state plan amendments to provide education, training, and counseling to family caregivers. Several states also incorporate flexibility into the types of training that can be provided to caregivers, often specifying a range of caregiver education, training, and/or counseling opportunities.
Recognizing that states depend on family caregivers to provide critical support to help relatives, friends, and neighbors, especially during the pandemic, NASHP will be publishing state resources on Medicaid policies supporting family caregivers through the RAISE Act Family Caregiver Resource and Dissemination Center with support from The John A. Hartford Foundation and in collaboration with the US Administration for Community Living. NASHP will analyze topics including respite services, reimbursement for caregivers, and paid leave in its future work.
Note: State-only funded programs as well as waivers and amendments for children and people with intellectual/developmental disabilities are not included in this analysis.
Information for Wyoming and Kentucky was not available for this analysis.
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) includes a Pandemic Unemployment Compensation benefit of $600 a week, which supplements traditional unemployment insurance (UI) benefits and provides an important source of additional financial support for individuals who qualify for these payments.
However, as highlighted in NASHP’s April 6, 2020 blog, Federal Guidance Needed to Clarify CARES Act Health Coverage Provisions, because these supplemental payments are counted as income for determining eligibility for marketplace subsidies – but not counted when determining eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) – there could be challenges for both individuals and states.
States are required to use streamlined applications across their health coverage programs and several states (CT, DC, CO, MA, MD, MN, RI, VT, and WA) have developed fully integrated eligibility systems shared by their Medicaid and state marketplaces. States must closely coordinate across these agencies as any changes to application instructions or questions could have ramifications for eligibility determinations between the programs.
The Centers for Medicare & Medicaid Services (CMS) recently released guidance that provides information on ways that states can identify the $600 weekly payments that are to be disregarded when determining Medicaid and CHIP eligibility. While the guidance gives states implementation flexibility, the options offered could be burdensome for both state Medicaid and CHIP agencies and individuals. Some of the issues include:
- Complications in coordinating with state unemployment offices: The guidance suggests that state Medicaid and CHIP agencies can work directly with their state unemployment agencies to determine which individuals will qualify for the additional payments. Yet, implementing a plan to identify these individuals in close coordination with unemployment agencies that are already significantly stressed with handling increased consumer demand is expected to be challenging for states.
- Challenges in implementing system changes: CMS notes that state unemployment agencies have the option to include the supplemental payments within their regular UI payments, or make the supplemental payments separately, which could help identify the $600 supplement for health coverage purposes. Separating the supplemental $600 payment from an individual’s regular UI may create additional work for the unemployment agency at a time when they are least able to accommodate additional work, but it could help both Medicaid and CHIP agencies (and although not referenced in the guidance, the marketplaces) to account for those separated funds in eligibility calculations.
CMS suggests that if state Medicaid and CHIP agencies can identify and document that all UI recipients will receive the additional payments, they will be able to program their eligibility systems to automatically reduce all UI income by $600 per week until the additional payments end on July 31, 2020. While the guidance indicates that states can potentially receive a higher federal match rate for making these system changes, quickly implementing them on a temporary basis will be administratively difficult for states – and it also assumes that states will have the ability to determine that all UI recipients are eligible for the additional payments.
- Relying on individuals to correctly report income could create eligibility determination complications: CMS indicates that states can choose to provide instructions in application forms or in their call center scripts to direct individuals to not report the $600 per week additional payments in their income for Medicaid and CHIP eligibility determinations. States can also ask that individuals self-attest about whether or not their UI income includes the $600 per week of additional payments. But some individuals may still mistakenly report the supplemental payments or not provide the correct information about whether their UI income includes the additional payments, which could negatively affect their Medicaid or CHIP eligibility. It could also hamper the ability of states to make accurate eligibility decisions and could result in state eligibility determination workers having to conduct extensive outreach to clarify applicants’ income information.
An important, remaining issue is that the CMS guidance does not address how states should align Medicaid and CHIP eligibility determinations with the fact the CARES Act requires the $600 supplemental payments to be counted as income when assessing eligibility for marketplace subsidies. This is particularly concerning for low-income consumers who are deemed ineligible for Medicaid and then are deemed eligible for low or zero marketplace subsidies because the inclusion of the supplemental payments has pushed them into an even higher income threshold. Concerns also remain about whether consumers might face penalties for inaccurately reporting income because of confusion caused by the different reporting requirements.
Additional federal guidance from the Center for Consumer Information and Insurance Oversight is needed to ensure that states can make accurate and timely eligibility determinations and that individuals are efficiently enrolled in health coverage.