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State Medicaid programs can only waive copayments for coronavirus testing and treatment if they also suspend copayments for all services, unless they seek a time-consuming Section 1115 waiver, the CMS said Thursday in a new Medicaid guidance to the states on COVID-19.
The agency released the 11-page frequently asked questions document following pressure from states and health plans for policy guidance on how they can deploy Medicaid and the Children's Health Insurance Program more effectively in addressing the pandemic.
It discussed ways states can gain greater flexibility through waivers, eligibility and enrollment changes, telehealth, prescription refill rules, and eased healthcare workforce requirements.
State Medicaid programs do not need federal approval to cover telehealth services in the same manner and at the same rate they pay for face-to-face services, the CMS said. In case of workforce shortages, states can expand the types of providers authorized to deliver services by filing a state plan amendment.
"The Trump administration is actively working with governors to provide flexibility in Medicaid and CHIP programs, so states can respond effectively to this virus," said CMS Administrator Seema Verma in a news release.
The agency said senior CMS leaders held a call last week with all state Medicaid agencies. On Wednesday, CMS officials met with leaders of Medicaid Health Plans of America, who asked the agency to establish consistency in how states and plans address the coronavirus outbreak.
But observers felt the administration was slower in addressing Medicaid's response to the pandemic than in dealing with Medicare and commercial insurance issues. The administration has consistently sought to cut back Medicaid enrollment and spending.
"What I'm hearing from my clients is there is a lot of policy coming out of the CMS related to Medicare and not enough on Medicaid," said Kinda Serafi, a partner at Manatt Health who consults with state Medicaid agencies. "The states are very eager for clarification on all these issues."
The Trump administration has pushed commercial insurers and Medicare Advantage plans to quickly waive cost-sharing for COVID-19 testing, to encourage Americans who think they have been exposed or infected to get tested and thus slow the spread of the disease.
But the CMS said state Medicaid programs would have to eliminate copays for all services if they want to reduce financial barriers to COVID-19 testing through a state plan amendment, which can be done quickly. If they aren't willing to erase all copays, they'd have to apply for a Section 1115 waiver, which can take months to get approved.
"Having to eliminate co-payments for an entire program in order to eliminate co-payments just for COVID-19 may give some states pause," Serafi said.
States that already have eliminated Medicaid copayments for COVID-19 testing include New Jersey, New York, and Washington. While copays in the Medicaid program are relatively small, ranging from $1 to $5, experts say they could discourage low-income people from getting tested for the coronavirus.
Medical care can't be denied to Medicaid enrollees with incomes below 100% of the federal poverty level based on nonpayment of copays. But copays can be enforced against enrollees with incomes above that threshold.
Some Medicaid health plans on their own are waiving copays related to COVID-19 testing and treatment, said Craig Kennedy, CEO of Medicaid Health Plans of America. "But this is an emergency," he added. "We would love it to be consistent for all 72 million Medicaid beneficiaries."
Medicaid plans, state officials, and policy experts also sought CMS guidance on whether they could ease enrollment and re-enrollment processes to get and keep people covered in order to ensure they get testing and treatment as the pandemic advances. The CMS has tightened eligibility redetermination to enhance program integrity, reducing Medicaid enrollment by hundreds of thousands.
In the new FAQ, the agency said states that have chosen to conduct eligibility redeterminations more frequently than once a year may submit a state plan amendment to extend the renewal period to one year.
Some experts also have urged the CMS to do what it has done in past emergencies and approve fast-tracked waivers temporarily extending Medicaid coverage to people who are affected, as happened following Hurricane Katrina and other catastrophes.
The new FAQ said states can choose to expand coverage by raising income eligibility standards for some populations through a state plan amendment, but that expansion could not be applied only to people affected by COVID-19. That's the process for permanently expanding Medicaid under the Affordable Care Act.
Some observers predict that the coronavirus outbreak may prompt states that have not expanded Medicaid to reconsider if low-income people who lack health insurance start showing up in large numbers at healthcare facilities with virus exposure or actual infection.
"I could see the combined forces of an economic downturn and the coronavirus causing states that haven't expanded to do so," said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation.
But so far GOP opponents of expansion in North Carolina, Georgia, Kansas, and other states haven't budged. In North Carolina, GOP legislative leaders have been locked for months in a budget impasse with Democratic Gov. Roy Cooper over his push for expansion.
"I don't believe there is any change in attitudes toward expansion because of the current state of the potential pandemic," said Rep. Donny Lambeth, a North Carolina Republican who supports expansion with a work requirement.