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State Medicaid and CHIP Strategies to Protect Coverage during COVID-19

July 2, 2020/in COVID-19 Charts, Featured News Home CHIP, CHIP, COVID-19, Eligibility and Enrollment, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Health Equity, Maternal, Child, and Adolescent Health, Population Health /by Gia Gould

State Immunization Services and Policies Resource Page

June 23, 2020/in Policy Toolkits Chronic Disease Prevention and Management, Healthy Child Development, Immunization, Maternal, Child, and Adolescent Health, Population Health, Social Determinants of Health Immunization /by Rebecca Cooper

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.

Resources

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.

View Each State’s Efforts to Extend Medicaid Coverage to Postpartum Women

June 22, 2020/in Policy Charts, Featured News Home Eligibility and Enrollment, Eligibility and Enrollment, Health Coverage and Access, Maternal Health and Mortality, Maternal, Child, and Adolescent Health /by NASHP Staff

Support Grows for Congressional Action to Boost Medicaid Matching Funds to Help States

June 1, 2020/in Policy Blogs, Featured News Home Chronic Disease Prevention and Management, COVID-19, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, Population Health /by Trish Riley

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.

In late April, the nation’s governors reached bipartisan support for a broad set of recommendations to help states address the COVID-19 pandemic and its devastating impact on their budgets. In their letter, the governors asked Congress to increase the states’ Federal Medical Assistance Percentage (FMAP) to 12 percent, retroactive to Jan. 1, 2020, to be maintained until the nation’s unemployment rate stabilizes at 5 percent.

In 2009, Congress temporarily raised the FMAP rate by 12 percent during the Great Recession to help states with shortfalls. In March, Congress again temporarily raised it by 6.2 percentage points in its Families First Coronavirus Response Act, but governors and their allies point out that more is needed.

View the National Governors Association letter to Congress requesting a 12 percent FMAP increase here.

Read the coalition’s letter supporting the governors’ request here.

States are reeling under the demands to address the COVID-19 pandemic and the economic impact of the disease. With state revenues significantly lower than projections, states are raiding rainy day funds and planning for budget cuts.

In their letter endorsing the governors’ request for a FMAP rate hike, 20 organizations that represent a wide range of health care and insurance plans, including the Blue Cross Blue Shield Association, America’s Health Insurance Plans, the American Federation of State, County and Municipal Employees (AFSCME), the Service Employees International Union (SEIU), the American Medical Association, and America’s Health Insurance Plans, cited a Congressional Budget Office forecast that predicted states would face shortfalls of approximately $650 billion in the next three years.

“As a direct result of the COVID-19 pandemic, state leaders will be forced to enact deep Medicaid cuts that could cause millions of Americans to lose access to critical health care services,” they noted. “To avoid these consequences and to protect health care access for over 70 million Americans, we call on Congress to enhance federal financing for the Medicaid program by at least 12 percentage points, with additional support for those states hardest hit by the economic shockwaves.”

The supporters noted that private-sector and government agencies are working together to support “frontline health care heroes, patients, and businesses. “Increasing FMAP will support our state leaders, providers, and tens of millions of Americans who depend on Medicaid every day,” they wrote.

Early Evidence Suggests Increased Medicaid Enrollment Due to COVID-19

June 1, 2020/in Policy Blogs, Featured News Home CHIP, COVID-19, Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, Population Health, State Insurance Marketplaces /by Gia Gould

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.

Infographic: How State Medicaid Programs Can Use Telehealth to Serve Pregnant Women during COVID-19

May 4, 2020/in Policy Featured News Home COVID-19, Integrated for Pregnant/Parenting Women, Maternal Health and Mortality, Maternal, Child, and Adolescent Health, Medicaid Managed Care, Population Health /by Eddy Fernandez and Taylor Platt

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 Approaches to Family Caregiver Education, Training, and Counseling

April 28, 2020/in Policy Blogs, Featured News Home Chronic and Complex Populations, Chronic Disease Prevention and Management, COVID-19, Population Health, The RAISE Family Caregiver Resource and Dissemination Center /by Salom Teshale, Eliza Mette, Paige Spradlin and Wendy Fox-Grage

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.

Findings

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;
Medications;
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.

Conclusion

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.

CARES Act Funds Help Consumers, but Create Health Coverage Eligibility Challenges for States

April 20, 2020/in COVID-19 Blogs, Featured News Home CHIP, COVID-19, Eligibility and Enrollment, Health Coverage and Access, State Insurance Marketplaces /by Anita Cardwell and Christina Cousart

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.

Q&A: What States Should Know about the Medicaid FMAP Increase

March 30, 2020/in COVID-19 Blogs, Featured News Home CHIP, COVID-19, Health Coverage and Access, Medicaid Expansion /by Anita Cardwell

To help states address the coronavirus (COVID-19) pandemic, the Families First Coronavirus Response Act (FFCRA) provides all states and territories with a temporary and retroactive 6.2 percentage-point increase in Medicaid’s federal medical assistance percentage (FMAP) — which determines the federal government’s share of Medicaid expenditures. Last week, the Centers for Medicare & Medicaid Services (CMS) released guidance on the implementation of the increased FMAP. This Q&A highlights some of its main points.

For what time period is the 6.2 percentage-point FMAP increase in place?

The increased FMAP is retroactive to Jan. 1, 2020. Because the Secretary of the Department of Health and Human Services (HHS) declared a public health emergency for COVID-19 on Jan. 31, 2020, the increased FMAP is available for qualifying expenditures that were incurred on or after Jan. 1, 2020. The guidance indicates that expenditures are considered to be incurred not based on the date of service, but instead on when the state makes a payment to a provider. The increased FMAP will continue through the last day of the calendar quarter in which the public health emergency ends.

Do states have to meet certain requirements to receive the FMAP increase?

Yes. States must meet the following conditions to receive the FMAP increase:

States need to maintain Medicaid eligibility standards, methodologies, and procedures that are no more restrictive than those that were in place as of Jan. 1, 2020;
States cannot charge higher premium amounts than those in place as of Jan. 1, 2020;
States must continue to provide Medicaid coverage to all individuals enrolled on or after March 18, 2020, until the last day of the month when the emergency period ends, regardless of any changes in individuals’ circumstances that otherwise would result in termination (unless an individual voluntarily dis-enrolls or moves out of state); and
States must provide Medicaid coverage without cost sharing for COVID-19 testing and treatment, such as vaccines, equipment, and therapies, during the emergency period.

States are also not permitted to require political subdivisions of the state to pay a greater amount of the non-federal share of expenditures than what was required as of March 11, 2020.

How will CMS verify state compliance with the requirements for receiving the increased FMAP?

Rather than having to submit a demonstration of compliance prior to drawing down the funds associated with the increased FMAP, CMS is asking states to attest to their compliance with the requirements. By virtue of drawing down the funds, states will be considered as “attesting” that their state is eligible for the increased FMAP. A state will be required to return the funds if CMS finds that a state’s attestation is incorrect.

What types of Medicaid expenditures qualify for the FMAP increase?

The FMAP increase applies to all Medicaid expenditures that use the regular FMAP rates. The guidance indicates that the increased FMAP is available for Medicaid Disproportionate Share Hospital (DSH) expenditures as well as any Medicaid waivers or demonstrations that use the regular FMAP.

What types of Medicaid expenditures do not qualify for the FMAP increase?

Some of the key Medicaid expenditures that the increased FMAP does not apply to include:

Administrative expenditures;
Expenditures related to the Affordable Care Act’s Medicaid expansion population; and
Other expenditures that are matched at a higher rate than the regular FMAP, such as family planning services, health home services, etc.

For a full list of Medicaid expenditures that the FMAP increase does not apply to, see pages 1-2 of the guidance.

What must states do to document which expenditures they are claiming are at the increased FMAP rate, and which are matched at other rates?

CMS is requiring that states document expenditures in ways that isolate the expenditures that are eligible for the increased FMAP. CMS is in the process of modifying reporting forms (e.g., CMS-64 and CMS-37) to accommodate FFCRA changes and will be offering states additional guidance and training related to reporting requirements.

Does the FMAP increase apply to the Children’s Health Insurance Program (CHIP)?

Yes, but not as a direct 6.2 percentage-point increase added onto states’ current enhanced CHIP federal matching rates (called the EFMAP). States’ EFMAPs for CHIP are calculated by using the regular FMAP as a base, and therefore because the FFCRA increases the FMAP, the EFMAPs increase accordingly. Given this, all states’ EFMAPs will increase by 4.34 percentage points through the public health emergency period, in addition to the 11.5 percentage-point increase in the EFMAP that is currently in place for federal fiscal year (FFY) 2020 and was provided for by the 2018 CHIP reauthorization law.

Below is an example of how the increase will apply (with the inclusion of the FFY 2020 11.5 percentage-point increase). In this case, a state’s federal CHIP match rate will increase from 76.5 percent to 80.84 percent:

Example of the impact of the 6.2 percentage-point FMAP increase on CHIP’s EFMAP

	Without 6.2 percentage-point FMAP increase	With 6.2 percentage-point FMAP increase
FMAP	50%	56.2%
EFMAP	65%	69.34%
EFMAP for CHIP in FY 2020	76.5% (65% + 11.5%)	80.84% (69.34% + 11.5%)

This is a modified version of the table included on page 3 of the CMS guidance. The EFMAP without the 11.5 percentage-point increase will be used for optional breast and cervical cancer expenditures.

Do the requirements to maintain coverage to receive the increased FMAP apply to CHIP?

No — states are not required to maintain coverage in CHIP to receive the increased FMAP. However, states are required to comply with the maintenance of effort provisions within the 2018 CHIP reauthorization law.

Can states continue to conduct Medicaid eligibility redeterminations or address enrollees’ changes in circumstances that may affect eligibility during the emergency period?

Yes, states are permitted to do so, however, to receive the increased FMAP, states are not allowed to terminate coverage for any individual who was enrolled in Medicaid on or after March 18, 2020, until the last day of the month in which the emergency period ends (unless the individual requests a voluntary termination or is no longer a state resident). Also, if a state receives information during the emergency period that would make an individual eligible through a different eligibility category, the state could move that individual to another eligibility group, if it provides additional benefits. However, states would not be able to do this if such a change would result in reduced benefits for the enrolled individual.

How and when will CMS provide the FMAP increase?

CMS will automatically provide the FMAP increase, and states do not need to submit a state plan amendment to receive the increase. The guidance indicates that CMS is in the process of providing the funds, and that states should have received them in their Payment Management System accounts by March 25, 2020 for the Jan. 1-March 31, 2020 time period. For the quarter that begins April 1, CMS intends to provide the funding for the increased match as close to that date as possible.

How the Families First Coronavirus Response Act Affects State Medicaid Programs

March 24, 2020/in Policy Blogs, Featured News Home Eligibility and Enrollment, Essential Health Benefits, Health Coverage and Access, Medicaid Expansion, Workforce Capacity /by Anita Cardwell

Last week, the Families First Coronavirus Response Act was signed into law to provide additional resources to help states address the effects of COVID-19. The law eliminates patient cost sharing for COVID-19 testing and related services in most forms of health coverage, it establishes an emergency paid leave program, extends sick leave benefits, and expands unemployment and nutrition assistance. It also includes additional funding for different agencies and offices within the US Department of Health and Human Services as well as funding for the Public Health and Social Services Emergency Fund.

Specifically for Medicaid, the law:

Prohibits cost sharing for COVID-19 testing and testing-related services during the public health and national emergency period.
Provides states with the option to extend Medicaid eligibility to uninsured individuals, specifically to provide coverage for COVID-19 diagnostic testing and testing-related services during the public health emergency period. If states choose this option, their related medical and administrative costs for this would be fully matched by the federal government. States can also receive payment for out-stationed eligibility workers and the use of streamlined applications for uninsured individuals covered by this provision.
It includes an increase in federal Medicaid funds to states and territories by providing a temporary and retroactive 6.2 percentage point increase in the regular Medicaid matching rate. The temporary increase in the Federal Medical Assistance Percentage (FMAP) would last through the final day of the calendar quarter when the emergency period ends. However, in order to receive the increased FMAP, states would be required to meet certain conditions:
- States would need to maintain Medicaid eligibility standards, methodologies and procedures that are no more restrictive than those that were in place as of Jan. 1, 2020;
- States can also not charge higher premium amounts than those in place as of Jan. 1, 2020;
- States must continue to provide benefits to individuals enrolled until the last day of the month when the emergency period ends (unless an individual voluntarily dis-enrolls or moves out of state); and
- States must provide Medicaid coverage without cost-sharing for COVID-19 testing and treatment, such as vaccines, equipment, and therapies, during the emergency period.

Guidance for states, along with additional details about implementation of these provisions will be forthcoming from the Centers for Medicare & Medicaid Services.