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The Trump administration and state leaders are facing pressure to quickly issue policies enabling state Medicaid programs to more effectively address the coronavirus outbreak.
Health plans, state officials, and Medicaid experts are urging policymakers to declare that state Medicaid programs will cover COVID-19 testing and treatment for Medicaid-eligible people without patient cost sharing, which the Trump administration has pressed commercial insurers to do. Some have also suggested temporarily expanding coverage to low-income adults exposed to the virus in the 13 states that have not expanded Medicaid under the Affordable Care Act.
Leaders of Medicaid Health Plans of America said they met with CMS officials late Wednesday to ask the agency to issue a guidance to the states to establish consistency in how states and plans address the outbreak. That includes covering telehealth services and waiving cost sharing and prior authorizations for Medicaid enrollees who have or are suspected of having COVID-19.
"We'd like CMS to say these are best practices and this is what we'd encourage you to do," said Craig Kennedy, CEO of Medicaid Health Plans of America, who declined Thursday to comment on the outcome of the meeting. "We'd love it to be consistent for all 72 million Medicaid beneficiaries."
At least one state is talking to the CMS about easing Medicaid rules. Washington is considering asking the CMS for either a Section 1115 or 1135 temporary waiver to allow it to modify Medicaid payment and other rules governing telehealth, healthcare worker certification, eligibility for elderly and disabled people, and coverage for supportive services like housing. HHS can grant Section 1135 waivers when the president declares a disaster or emergency.
"We need to get all sorts of paper and eligibility barriers out of people's way," said Susan Birch, director of the Washington State Health Care Authority, adding that the CMS has been very responsive but that archaic waiver processes have slowed things down.
A CMS spokeswoman said the agency is "in ongoing discussions with states about the flexibilities available to them through the Medicaid program to pay for services related to COVID-19."
Trump administration officials, who have consistently sought to cut back Medicaid eligibility and spending, previously had offered no indication that they were considering granting waivers or greater coverage or payment flexibility. In a fact sheet issued March 5 on coronavirus coverage for Medicaid, the CMS did not address offering states more flexibility or funding to address the developing epidemic.
Instead, the agency noted that states can charge low-income beneficiaries premiums and copayments, and that enrollees may be held liable for unpaid copayments.
"That sounds like people who are tone deaf," said Joseph Antos, a conservative health policy analyst at American Enterprise Institute. "I would expect that within weeks there will be some further guidance saying it's up to the states to do what they want on that. But the political cost of saying we won't give you a (coronavirus) test if you don't fork over $5 is pretty dramatic."
State officials and Medicaid plan leaders urgently want the CMS to help them with nitty-gritty operational issues such as workforce flexibility if healthcare workers need to be quarantined; updating telehealth coverage policies; easing prescription drug refill rules; and covering services in non-traditional settings, including non-medical supports.
Some also want the agency to consider easing enrollment processes and extending coverage to populations at risk for contracting the coronavirus, such as the elderly and disabled and undocumented residents. Birch said it would help to be able to enroll vulnerable seniors much more quickly than under the typical 90-day eligibility determination process.
Other experts want the Trump administration to go further, emulating what the Bush administration did following the 9/11, Hurricane Katrina, and Iowa tornado and flood catastrophes. In those situations, the administration declared a public health emergency, and the CMS approved fast-tracked waivers temporarily extending Medicaid coverage to tens of thousands of affected people. The government eased documentation requirements and waived standard budget neutrality rules.
"The HHS secretary should give temporary coverage to uninsured people who are potentially affected by the virus, so there's no question that there's a payer for these services," said Sara Rosenbaum, a health policy professor at George Washington University.
A coverage expansion could become crucial if the pandemic knocks the U.S. economy into recession and many Americans lose their jobs and employer health insurance, some Medicaid experts argue.
During and after the Great Recession, national Medicaid spending jumped 14.7% from 2007 to 2009, driven by an enrollment increase of nearly six million, according to the Kaiser Family Foundation. A federal stimulus bill helped states fund that Medicaid spending spike, which lasted until 2011.
But Rosenbaum said this isn't the time to re-litigate permanent Medicaid expansion. Instead, policymakers should look for the fastest way to get care to people with COVID-19 or who are at risk of transmitting or contracting it.
"Full expansion is not the emergency issue now," she said. "The thing now is for (the CMS) to get out of the states' way, make Medicaid work faster and better, and open the door to temporary coverage," she said.