States have an increasing interest in extending Medicaid coverage from 60 days to 12 months postpartum, driven by states’ priorities for ensuring continuity of coverage and addressing the maternal mortality crisis. To extend this coverage, states can request approval from the Centers for Medicare and Medicaid Services (CMS) under Medicaid Section 1115 demonstrations. Through a new provision included in the American Rescue Plan Act (ARPA), states can now also extend postpartum coverage through a Medicaid state plan option (SPA). Under the SPA option, states must provide full benefits during and throughout the 12-month postpartum period. If a state covers pregnant people through the Children’s Health Insurance Program (CHIP), it must also elect to extend coverage through CHIP. This state plan option is only available for a five-year period starting April 1, 2022.
As described in more detail below, two states – Illinois and Missouri – recently received approval from the Biden Administration for the extension of Medicaid postpartum coverage. Washington State has enacted legislation to extend Medicaid postpartum coverage and will submit a SPA to CMS for this authority. There are another 33 states that have introduced legislation or enacted legislation to seek federal authority to extend Medicaid coverage to 12 months postpartum. Some states are seeking a full coverage extension for all eligible pregnant people, while other states are defining specific eligibility groups, benefit coverage, and length of the extension (i.e., six-months postpartum).
The maternal mortality crisis continues to be a significant challenge across states. More than half of pregnancy-related deaths occur during the postpartum period, or the period following birth, and 12 percent occur after six-weeks postpartum. Black women are three to four times more likely to die from a preventable pregnancy-related complication compared to non-Hispanic white women; women of color also experience higher rates of uninsurance compared to white non-Hispanic women. Lapses in or loss of coverage may exacerbate existing chronic conditions, such as depression and hypertension, which can contribute to poor maternal health outcomes. Churn, or moving between insurance plans or becoming uninsured, can also pose a serious risk to pregnant people by disrupting care and potentially exacerbating existing health conditions. Higher rates of churn and uninsurance among pregnant women are found in states that have not expanded Medicaid under the ACA.
Extending Medicaid postpartum coverage is a key strategy to address maternal mortality and loss of coverage. Currently, Medicaid coverage for pregnant people lasts until 60 days postpartum and individuals are typically disenrolled on the last day of the month. After this period, postpartum people may:
- requalify for Medicaid if they live in a state that has expanded Medicaid and they meet expansion eligibility criteria, including the income requirements,
- requalify for Medicaid if they are a parent with a dependent child and meet eligibility criteria, including the income and age requirements,
- seek private coverage through the individual marketplace, which generally includes premiums and higher out-of-pocket spending compared to Medicaid, or
- become uninsured.
The following describes three states’ efforts to extend postpartum coverage through a Medicaid section 1115 waiver or through a state plan option, as allowed under ARPA.
In May of 2021, CMS approved Illinois’ request to expand full Medicaid coverage from 60 days to 12 months postpartum under a Medicaid Section 1115 demonstration. The goal of this extension of coverage is to reduce health disparities and strengthen continuity of coverage by allowing mothers to stay with their existing providers, prevent gaps in insurance coverage, and provide access to needed care, including behavioral health services and services to manage chronic conditions, such as diabetes and hypertension, during the full postpartum period.
In 2018, Missouri enacted a law allowing the state to seek federal authority to extend Missouri HealthNet (Medicaid) benefits for postpartum women who are diagnosed with a substance use disorder (SUD) within 60 days of giving birth. The state submitted an 1115 Demonstration waiver, which was approved by CMS in March 2021. Women who meet the criteria of the Missouri Targeted Benefits for Pregnant Women Demonstration program will be eligible for SUD treatment, as well as treatment for mental health conditions related to SUD for up to twelve months following delivery. The intent is to improve access to quality treatment for SUD, and mental health conditions related to SUD, for women who recently gave birth. Anticipated results include increased adherence to and retention of SUD treatment plans; reduction in SUD-related hospitalizations and emergency room visits; strengthened safeguards for the health of women and children during the postpartum period and first year of the newborn’s life; and improvement in health outcomes for women and children.
In May 2021, Washington State enacted a law to extend Medicaid postpartum/post-pregnancy coverage to 12 months, with an implementation date of June 2022. The state plans to submit a SPA to CMS, as allowed under ARPA. Under the law, the state will also provide coverage for undocumented individuals who do not qualify for Medicaid coverage but whom are in the window of up to 12 months postpartum. The law will also provide coverage to individuals who had any end of pregnancy outcome.
Promoting continuity of coverage is a critical strategy for addressing the maternal mortality crisis. NASHP expects states to continue pursuing postpartum coverage extensions, particularly through the state plan option under ARPA. For more information on state actions to extend postpartum coverage, visit NASHP’s Extending Postpartum Coverage Tracker, which is updated monthly.
In late June, the U.S. Department of Health and Human Services (HHS) issued its first proposed rule governing the health insurance markets and marketplaces. The rule includes some significant changes aimed at achieving priorities outlined in President Biden’s Executive Order to strengthen provisions within Medicaid and the Affordable Care Act (ACA).
Major changes proposed by the rule are summarized below. Comments on the rule may be submitted here by July 28.
Extends open enrollment period for an additional month
The proposed rule would extend the open enrollment period (OEP) deadline from December 15 to January 15. The change would apply to both federal and state-based marketplaces (the FFM and SBMs) and if finalized, would begin with this upcoming enrollment period, which is slated to begin on November 1, 2021.
The December 15 deadline has been in place since the 2018 plan year. States that operate their own marketplaces (SBMs) have flexibility to extend their deadlines beyond this period, and many opt to do so depending on the needs within their markets. Both the FFM and SBMs also have the ability to extend special enrollment periods (SEPs) particularly in the case of exceptional circumstance, as many did to address changing circumstances during the COVID-19 pandemic.
The proposed rule acknowledges that altering the years-long standing deadline may spur consumer confusion and that the current the December 15 deadline ensures that coverage for enrollees will be effective for the full year starting January 1. However, the proposed rule explains that the 45-day enrollment period does not provide sufficient time to assist all applicants and that additional time is needed for these consumers to sufficiently update information and review available plan options. Specifically, the rule cites a pattern of unexpected cost increases experienced by consumers who were automatically reenrolled into a plan without realizing the amount of their federal premium tax credits (PTCs) had decreased due to the existence of lower cost “benchmark plans” (the insurance plan against which PTCs are set). In these cases, the enrollees’ January bill may be the first time they become aware of cost changes and the January 15 deadline gives enrollees some leeway to switch before being locked into a potentially unaffordable option for a year.
Beyond requesting information on potential impacts of the proposed rule on insurance markets and enrollees, HHS is soliciting ideas for proposed alternate strategies, including possible institution of an SEP for enrollees who experience cost increases because of changes to their benchmark plan. In addition, HHS invites comments on flexibilities given to SBMs related to OEPs and SEPs.
Modifications to Section 1332 state innovation waiver program
Section 1332 waivers grant states the option to waive significant portions of the Affordable Care Act (ACA) so long as proposals meet four statutory guardrails:
- Provision of coverage at least as comprehensive as that offered under the ACA
- Provision of coverage as least as affordable as that offered through the ACA
- Assurance that a comparable number of individuals will be insured; and
- Assurance the plan will not increase the federal deficit.
Guidance issued in 2018, and further promulgated in later regulation, set a new interpretation of the guardrail definitions limiting how strictly all of a state’s proposed waiver changes needed to adhere to the guardrails. For instance, the 2018 regulation provided a looser definition of coverage that allows health plans that do not meet the ACA’s standards (ex. short-term plans) meet the criteria of the guardrails. (For more on the 2018 changes see: New Guardrail Definitions Reduce Minimum Requirements for Markets)
Further, HHS proposes to rescind recent rules and guidance, reinstating prior rules requiring that all coverage under a states’ waiver meet the guardrail requirements and clarifying that “coverage” means minimum essential coverage as defined under the ACA. The proposed rule also clarifies some processes related to waiver applications including reinforcing that HHS will not take into consideration waiver proposal elements contingent on the enactment of future state laws or waiver changes (e.g., Medicaid Section 1115 waivers). It also would codify a process by which states may request waiver amendments and clarifies that waiver funding may be adjusted annually based on changes in federal or state laws.
New SEP for low-income households eligible for $0 coverage
The proposed rule would institute a new SEP for individuals and families whose income is up to 150% of the federal poverty level (FPL), allowing them to enroll in marketplace coverage at any point during the year. The change is a direct response to the American Rescue Plan Act’s (ARP) temporary enhancements to the amount of PTCs available to all qualified individuals enabling individuals up to 150% FPL to enroll in a benchmark plan for $0 per month. Prior to the increased subsidy, these individuals would have to pay up to 4.14 percent of their income to purchase a benchmark plan.
The SEP would limit options by allowing eligible individuals to only enroll in a silver-level plan sold through the marketplace. Silver-level plans pose two advantages to enrollees at this income level. First, benchmark plans are set as the second-lowest cost silver plan available to that consumer, so most silver plans could be purchased at $0 to very low cost to the consumer. Second, individuals with income that is less than 250% FPL who enroll in a silver plan also qualify for cost-sharing reductions (CSRs), or subsidies that cover the cost of out-of-pocket expenses such as deductibles and co-pays. Low premium payments and CSRs combine to ensure enrollees high-value health coverage at little to no personal expense.
The SEP would be coupled with dedicated outreach efforts to spread awareness about the opportunity especially to the 20 percent of uninsured individuals estimated to live in households with income below 150% FPL. HHS doesn’t dictate when the SEP would be enacted and proposes to grant discretion to the SBMs about whether to implement the SEP. The proposed rule also doesn’t include requirements for document submission prior to eligibility determinations. HHS requests comments on these issues as well as on anticipated impacts of the policy on insurance markets including adverse selection.
The proposed rule also highlights the potential impact of this SEP given the impending end of the COVID-19 public health emergency (PHE). During the PHE, states are prohibited from disenrolling individuals from their Medicaid programs. Once disenrollments resume, marketplaces are expected to experience an influx of enrollees, particularly of individuals with income below 150% FPL. Currently, these enrollees would qualify for a 60-day SEP triggered by loss of essential coverage, but the proposed SEP would allow these individuals to enroll beyond that 60-day period. (See this blog offer more details about Medicaid and the end of the PHE.)
Reinstates required Navigator program post-enrollment duties
Every marketplace is required to institute a Navigator program—a network of community-based individuals trained to aid consumers with procuring health insurance coverage with a particular focus on serving underserved or vulnerable populations. Recognizing that many enrollees, especially in these targeted communities, need assistance beyond just applying for and enrolling in coverage, the proposal reinstates requirements for post-enrollment assistance
eliminated in the 2020 notice of benefits and payment parameters rule. Specifically, the rule would require Navigators to aid enrollees on topics including eligibility appeals, PTC reconciliation, and basics of using and accessing care. Furthermore, the rule broadens the interpretation of activities to support “use of and access to care” to include help with understanding:
- key health insurance terms,
- cost differences between use of emergency and primary care under selected plans,
- how to identify in-network providers,
- rights to coverage of certain preventive services without cost sharing, and
- common follow-up steps to care such as how to fill prescriptions.
To accomplish these tasks, the rule suggests that Navigators may leverage resources from the Centers for Medicare and Medicaid Services’ Coverage to Care initiative. These reinstated requirements were also reinforced in HHS’ latest funding announcement for Navigator grants.
Repeals Exchange Direct Enrollment option
Rules published in January 2021 established a new option by which states could leverage direct enrollment (DEs) entities in lieu of the FFM or SBM. DEs are private entities (ex., web-brokers, insurers) that are certified to sell marketplace coverage, though they may also sell other products including short-term plans. Individuals may apply for and enroll in coverage through enhanced DEs without ever interacting directly with a marketplace (e.g., healthcare.gov).
Beginning for plan year 2022, the new Exchange Direct Enrollment option would have allowed a state to abolish operation of the FFM or an SBM, and instead rely completely on DEs to enroll eligible individuals in coverage. HHS notes several reasons for proposing to eliminate the option including a need to focus resources on shifted priorities including implementation of the ARP. HHS also noted it had received no interest to date from states wishing to implement the option.
Increases federal marketplace user fee
Operation of the federal marketplace is financed through an assessment on monthly insurance premiums charged to all participating qualified health plan issuers. HHS is proposing a 0.5% increase to the assessment rate to 2.75% in states that use the FFM and 2.25% for states that use they hybrid federal partnership model (SBM-FP). The increases will be used to cover expanded federal services including increased investment in outreach and educational services. HHS anticipates that these investments will lead to improved risk pools, lower monthly premiums, and a reduction in the uninsured and comes on the heels of the federal government’s largest ever investment ($80 million) on Navigators.
Repeals “double-billing” requirement for abortion coverage
The proposed rule would repeal not-yet-implemented requirements on insurers to send separate bills and collect separate payments for premium expenses related to coverage of abortion services. Federal law prohibits use of federal dollars to pay for abortion coverage (except in certain circumstances). To ensure that federal subsidies (PTCs and CSRs) do not pay for such services, insurers are required to separate premium payments used to cover abortion services into a different funding pool and to alert enrollees of the charge by:
- Sending enrollees a notice that their monthly bill included this charge;
- Including the charge as a line item in the enrollees’ monthly bill; and/or
- Sending a separate monthly bill for these services.
Rules finalized in 2019 took these requirements further, mandating that insurers both send a separate bill for the abortion coverage and collect those premiums via payments separate from the enrollees primary premium payment. It was estimated the changes would cost $1 billion from 2020-2023, with $229 million in additional costs each ensuing year to implement.
The proposed rule would repeal 2019 requirements citing excessive administrative and operational burdens caused by the rule as well as ongoing litigation against the rule that had halted its implementation for reasons ranging from its inability to preempt state laws mandating certain billing procedures to incompatibility with federal laws preventing the promulgation of regulations that “create any unreasonable barriers to obtaining appropriate medical care or impede timely access to healthcare services”.
Essential Health Benefit (EHB) compliance with mental health parity
All marketplace plans are required to cover mental health and substance use disorder (SUD) services as part their benefits packages. The proposed rule would enact technical changes to clarify that coverage of mental health and SUD services must comply with all requirements of the Mental Health Parity and Addition Equity Act of 2008 (MHPAEA) including provision of behavioral health treatment services that meet the MHPAEA’s parity standards.
Data analysis is an essential tool for advancing health and racial equity. Geographic analysis of disease burden has illuminated the impact of racism and identified areas to target interventions. Spurred by the disproportionate impact of COVID-19 on communities of color, states are exploring new strategies to use COVID-19 and other public health data to advance health and racial equity. Convergence analysis, using publicly available data sets, is one such strategy.
Convergence analysis helps to depict the extent that different health conditions coexist at their worst level. Any dataset that is geographically referenced can be used for convergence analysis. State officials, and community groups, can conduct convergence analysis using publicly available datasets including those maintained by the Centers for Disease Control and Prevention (CDC) and the free version of ArcGIS.
In Denver, CO, data from the CDC Behavioral Risk Factor Surveillance System (BRFSS) 500 Cities project was used to determine burdens of the following diseases by census tract: asthma, chronic obstructive pulmonary disease (COPD), coronary heart disease, diabetes, high blood pressure, kidney disease, obesity, and stroke. Convergence analysis revealed that disease burden was greatest in six census tracts that included 32,019 people. African American and Latinx populations were overrepresented in these areas.
Similar convergence analysis was completed for Columbus, OH. Thirty-seven census tracts with a population of 114,835 had at least four of the health conditions at the highest level. In the identified census tracts, 54% of the population is African American, compared to 29% in Columbus overall. These census tracts also face 7.5% unemployment compared to 4.7% citywide.
Inequality and Social Vulnerability
The Mapping Inequality dataset from the University of Richmond can be incorporated into convergence analysis to provide a historical context of the impact of structural racism on health. The Mapping Inequality project digitized the Home Owners’ Loan Corporation (HOLC) maps used between 1935 and 1940. These maps assigned grades to neighborhoods based on their perceived mortgage security to banks and served as a tool for redlining and government-backed residential segregation.
In Denver, CO, areas that had the lowest HOLC grades also had the highest social vulnerability according to the CDC/ATSDR Social Vulnerability Index. The CDC/ATSDR Vulnerability Index identifies communities that may need the most assistance before, during or after a natural or human disaster. This analysis highlights the legacy of structural racism and its impact on health outcomes, especially regarding a community’s ability to respond to an emergency.
The Health Opportunity Index
The Health Opportunity Index is another data strategy for stakeholders invested in health equity. The Index was developed by Rexford Anson-Dwamena, MPH, an epidemiologist at the Virginia Department of Health. The tool can be used to identify which social determinants of health (SDOH) may be driving health disparities in communities at the census tract level.
In an analysis of Ohio’s major cities, the drivers of adverse health outcomes were income inequality, concentrated poverty, food insecurity and segregation. The Health Opportunity Index identifies the challenges and opportunities available to improve health.
State Health Equity Data Tools
The following are some examples of how states are using data to inform their health equity approaches:
- Massachusetts’ Public Health Data Warehouse is a “unique surveillance and research tool that provides access to timely, linked, multi-year data to enable analyses of health priorities and trends, such as the current opioid epidemic and persistent inequities in maternal and child health.” The commonwealth also operates the Population Health Information Tool, a health data portal that includes a health equity dashboard.
- New York maintains a Prevention Agenda Dashboard to track progress on the state’s health improvement plan. Data can be viewed at the sub county level.
- North Carolina created a map of areas with the highest rates of social vulnerability and lowest rates of COVID-19 vaccination. The state encourages vaccine providers to prioritize these areas for outreach and mobile efforts.
- Pennsylvania’s Health Equity Analysis Tool (PA HEAT) includes a dashboard and geographic analysis of health and social determinants of health information at the regional, county, zip code and census tract levels. The purpose of the tool is to “provide a granular geographic perspective of areas that have significant opportunities to improve equity.”
- Rhode Island used geographic analysis of COVID-19 cases during its response to focus on high density areas.
- Virginia’s Health Equity Leadership Taskforce created two dashboards to advance health equity. The Equity in Action dashboard describes how the state is prioritizing equity in COVID-19 response and recovery and the Equity-at-a-Glance dashboard is an assessment of six social determinants of health at the state and local level. The dashboard shows data on income and poverty, educational attainment, food access, unemployment, broadband access, and housing insecurity.
States looking to engage in data analysis to advance health equity face barriers including missing data, inconsistent standards, and poor tracking of data by race and ethnicity. These issues were illuminated by the COVID-19 pandemic. During the first month of COVID-19 vaccination, data for race and ethnicity was missing for roughly half of people who initiated vaccination against COVID-19. Complete data by race and ethnicity is essential for states to identify gaps in vaccination efforts and better reach historically marginalized populations with COVID-19 vaccines.
Current race and ethnicity categories also limit state officials’ full understanding of disparities among a subpopulation. For example, the category “Asian” covers many subpopulations. A recent Executive Order from the Biden Administration, encourages the Equitable Data Working Group to “expand the collection and use of disaggregated data at the Federal, State, and local level on Asian American, Native Hawaiian, and Pacific Islander communities.”
Further federal guidance could standardize categories and allow for clarity and consistency across federal, state, and local levels. Funding from the American Rescue Plan provides some opportunities for states to invest in their public health data infrastructure. The House Committee on Energy and Commerce is also considering legislation on data, social determinants of health, and health equity.
Access to data and the ability to analyze it geographically is important for helping state officials to equitably distribute resources to address health related social needs. Data analysis is a critical first step for state officials to use their financing, regulatory, and other levers to advance health equity. Creating data maps allows state leaders to visualize areas to prioritize for health equity strategies.
To read more about state initiatives to address health equity, explore NASHP’s toolkit, Resources for States to Address Health Equity and Disparities. If you are a state official interested in joining NASHP’s equity workgroup, please contact Allie Atkeson.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation. NASHP would like to credit Johnnie (Chip) Allen, MPH for sharing the referenced images and data strategies to advance health equity with NASHP’s health equity workgroup.
The COVID-19 pandemic has exacerbated adverse childhood experiences (ACEs), and children could be facing a surge of poor physical and mental health outcomes without adequate investment and focus to reduce the effects of ACEs. This is especially important because Black, Latinx, and Native American children, who already disproportionately experience higher levels of ACEs, have also been impacted by the COVID-19 pandemic, in part due to longstanding inequities. A number of states are taking action. States like California and New Jersey have launched statewide initiatives to mitigate the long-term effect of traumatic events, and several state legislatures have introduced bills to identify and address ACEs in partnership with systems such as Medicaid and education.
In New Jersey, the Department of Children and Families’ (DCF) Office of Resilience released a statewide action plan in 2021 with a goal of helping children and families in New Jersey reach their full potential by focusing on prevention and reduction of childhood trauma and adversity in future generations. The DCF Office of Resilience was created in June 2020 during the pandemic, to host, coordinate, and facilitate statewide initiatives with the purpose of raising awareness of and creating opportunities to eradicate ACEs through grassroots and community-led efforts. Key components to implementing the new action plan include:
- Conducting a statewide literature and programmatic review to assess current efforts to address ACEs in the state,
- Meeting with non-governmental organizations to ensure actions are community-led and centered, and collaboration to highlight and promote an online community, and;
- Making data from the New Jersey Population Health Cohort study publicly available.
Both state strategies center community voices and highlight resilience as a protective factor against trauma, and both plans work in stages by first identifying the breadth and depth of trauma in children through screenings, and then using this information to create appropriate resilience-focused programs. Both California and New Jersey strive to proactively address the impact of ACEs, especially as children are exposed to compounding trauma living through a pandemic and help build a healthier future.
Proposed State Legislative Strategies
COVID-19 has exacerbated existing stressors and the trauma from the pandemic has created new ones, and states have been having active discussions about how best to serve the needs of children during the pandemic. Against this backdrop, legislators across states are considering new strategies to address ACEs. Most states’ legislative cycles are reaching their end and bills are at various point in the legislative cycle, but common themes in proposed legislation include:
- Publicly acknowledging the impact of trauma and importance of trauma-informed care. Illinois SR 212 declared May 25, 2021 “Trauma-Informed Awareness Day,” to, among other things, encourage all employees of the State to become informed regarding the generational impacts of ACEs, toxic stress, and systemic racism.
- Creating entities to identify areas of need and recommendations. A bill in Georgia seeks to create a House Study Committee on ACEs to improve the health of women and children. The bill was introduced after data from the U.S. Health Resources and Services Administration showed that in 2019, 23.6% of Georgia children lived in economic hardship, that economic insecurity is the most common ACE, and non-Hispanic Black children are nearly twice as likely to experience one or more ACEs. Similarly, a Maryland bill proposes establishing a “Workgroup on Screening Related to Adverse Childhood Experiences,” tasked with updating and developing screening tools, submitting the screening tools to the Department of Health, studying best practices, and making recommendations to the Governor and General Assembly.
- Increasing ACE and social determinant of health screening for children by Medicaid and education agency stakeholders. State legislatures are exploring:
- Requiring home health care professionals to use ACE questionnaires to assess patient health risk with reimbursement by Medicaid (NY).
- Requiring school district board of directors to conduct ACEs screenings for any child before taking disciplinary action and including the results in any reports explaining the disciplinary results (AR).
- Screening students for ACEs or traumatic events (CT, MD, PA). Pennsylvania’s bill requests a comprehensive analysis to identify an age-appropriate measuring tool that can be used by school districts to measure childhood trauma. Maryland’s bill requires the Secretary of Health to approve ACE training programs that providers can complete, to be reimbursed by Medicaid.
Unfortunately, nearly 40,000 children lost parents to COVID-19, and sustained investments will be critical to mitigate the effects of the trauma experienced during the pandemic. States are at different stages of promoting ACE awareness and addressing the effects of ACEs–identification and screenings are just the first steps toward improving long term health outcomes. Ongoing efforts to shine a light on this issue are moving ACEs towards mainstream consciousness at a critical juncture. As strategies in California, New Jersey, and other states demonstrate, awareness, community engagement, provider training, and critical partnerships are the first steps toward ensuring that children’s needs are considered and met. NASHP will continue to monitor state action including use of American Rescue Plan Act Funds to address ACEs. See related NASHP resources.
The American Rescue Plan of 2021 (ARP) – signed into law on March 11, 2021 – provides states with a one-year, 10 percentage-point increase to the federal medical assistance percentage (FMAP) for Medicaid expenditures on home and community-based services (HCBS) for children and adults. This increase provides states with a critical opportunity to address both emerging and long-standing challenges in state long term care systems – systems that have been heavily impacted by the COVID-19 pandemic in the last 14 months. The Center for Medicare & Medicaid Services (CMS) issued a letter to State Medicaid Directors on May 13, providing additional guidance to states on how they can use this new funding.
Highlights from CMS guidance:
- The increased FMAP must be used to supplement, not replace, existing state funds spent on Medicaid HCBS in effect as of April 1, 2021.
- State funds equivalent to the amount of the increased FMAP can be used to facilitate activities that enhance, expand, or strengthen Medicaid HCBS.
- States are prohibited from imposing stricter eligibility requirements for HCBS programs and services than were in place on April 1, 2021, and may not eliminate covered services or reduce the amount, duration, or scope of those services during this period.
- CMS will not apply penalties or non-compliance restrictions to states once the authority for temporary changes to HCBS eligibility, coverage and/or payment rates (e.g., Appendix K waivers and disaster relief state plan amendments) has expired or if the state needs to implement changes to comply with federal requirements
- CMS will work with states making programmatic changes to revise cost effectiveness projections appropriately and determine the feasibility of their budget neutrality models.
While the enhanced FMAP increases federal funding for specific services, the impact of the 10% bump could have broader implications for state HCBS systems. States may use state dollars freed up by the enhanced match to “enhance, expand, or strengthen” Medicaid HCBS in myriad ways. State context and specific priorities will drive these investments, which could include:
- Bolstering workforce: COVID-19 has highlighted the need to better support the long-term care workforce. States can target resources to increase wages and benefits, facilitate vaccinations and other COVID protections, and invest in training and career pathway strategies to grow and sustain a diverse LTC workforce, including peers and community health workers.
- Addressing equity: Expanding access to HCBS services in underserved communities and communities of color is a critical priority across states: policy makers may choose to enhance cultural and linguistic capacity, assess and address equity through existing No Wrong Door Systems, and invest in community-based organizations that are located in and serve communities especially hard hit by the COVID pandemic.
- Supporting family caregivers: Families can be critical to keeping adults and children and youth with special health care needs (CYSHCN) at home or in community settings. States may want to increase services and supports for families, including respite; establish or strengthen family caregiver assessment and outreach; build greater cultural and linguistic capacity; enhance Medicaid self-direction programs that pay families and others to provide Medicaid services, and facilitate wider use of innovative technology.
- Investing in behavioral health recovery: The higher match rate is also available for services to support people in recovery from mental illness and substance use disorders. Enhancements could include strengthening community-based interventions that help people remain in housing or stay employed; building cross-system reentry capacity with state prisons or local jails; developing diverse peer support capacity for people with behavioral health disorders; improving transitions for youth with behavioral health needs, and promoting access to recovery options for children, youth, and adults in underserved areas.
Additional considerations for states
States will have to quickly identify priorities and focus areas, identify services available for the enhanced FMAP, and submit plans and budgets within a very narrow timetable. Other issues to consider:
Sustainability: The enhanced FMAP is only available for one year; additional state funds that result from the enhanced match are available to support HCBS activities through March 31, 2024. States that opt to expand access to HCBS will want to plan for sustainability of services, both after the initial one-year FMAP bump, and through 2024 when all additional resources need to be spent.
Waiver/SPA rules still apply: States may add new services to maximize impact of the FMAP bump, but may need to submit a waiver or state plan amendment to do so. CMS will work with states to ensure state compliance with cost neutrality and budgeting rules.
State planning and initiatives: States may already have legislative and other state policy initiatives in the works that impact their HCBS systems. These ongoing or upcoming initiatives may benefit from ARP funding and can be incorporated into state submissions.
The American Rescue Plan funding represents an important opportunity for state policy makers to address long-standing challenges in HCBS systems related to access, rebalancing, health equity, workforce, and other issues. Initial state plans are due to CMS within 30 days of May 13th. CMS indicates it will publicly post state plans; NASHP will track these plans as they are posted and share information on emerging themes.