Medicaid Disaster Relief SPA Template Suggests Positive Steps States Can Take During the COVID-19 Pandemic

CMS has created a helpful template to make it easier for states to make temporary changes to their Medicaid State Plans during the COVID-19 National Emergency. For most strategies, states need only check off options on the template or, in some cases, provide brief descriptions of the groups or populations affected by the change. The template is organized in seven categories, including: A – Eligibility, B – Enrollment, C – Premiums and Cost-Sharing, D – Benefits, including telehealth and drug benefits, E – Payments, F – Post-Eligibility Treatment of Income, and G – Other Policies and Procedures.

The instructions for completing the template offers helpful context. Importantly, it also states that other plan flexibilities must not restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers.

Eligibility – Under this section, states may choose to adopt the new “uninsured individual” group, as well as pick up other existing optional groups. And while other optional groups may be subject to income and asset standards, it is important to note that this is not required for the new uninsured group. This section also allows states to establish residency for individuals temporarily out-of-state or for individuals who may be considered residents of other states but are in the state temporarily. Additionally, it allows states to extend the reasonable opportunity period for non-citizens who have attested to a satisfactory immigration status that cannot be verified through electronic sources.

Enrollment – This section allows states to expand hospital presumptive eligibility (PE) to non-MAGI groups (seniors and individuals eligible based on disability). Importantly, it allows states to adopt or expand traditional presumptive eligibility, including designating the Medicaid agency, and other types of organizations as a qualified entities, as well as specifying new or additional groups to which PE applies. Of particular interest, this section allows states to deploy an even more simplified paper and/or online version of the model, single, streamlined application or the state alternative. New simplified applications must be submitted to CMS for review. It would be particularly helpful for CMS to create and post a model alternative or to at least document the minimum amount of information that must be collected in order to facilitate an eligibility determination in future guidance.

Premiums and Cost-Sharing – The template easily allows states to suspend both service-related cost-sharing as well as premiums, enrollment fees, or other monthly contributions. Suspended cost-sharing may be applied broadly to all charges, or limited by service type, or eligibility level or category.  However, more limited cost-sharing suspensions cannot be narrowly focused only individuals affected by a particular diagnosis, such as COVID-19. Short of suspending premiums and other enrollment charges, states may establish an undue hardship waiver for individuals but must describe their standard for determining undue hardship.

Benefits – States may add new optional benefits and make other temporary adjustments to covered benefits such as increasing the types of providers who are authorized to deliver certain services or to adjust any limitations on services. States must attest that any changes to benefits will comply with all existing statutory requirements, including applying them statewide and offering free choice of providers. This section also allows states to expand the use of tele-health and makes a variety of changes to drug benefits, including adjusting supply quantities, eliminating prior authorization, extending duration or quantity of drugs already approved through prior authorization, and/or establishing preferred drug list exceptions.

Payments – This section allows states to establish the payment methodology to newly covered optional benefits, to increase payment rates for current services, and alter the way they pay for tele-health services.

Post-Eligibility Treatment of Income – This section applies to temporary changes to how income is calculated for institutionalized individuals or to elect to modify the basic personal needs allowance.

Other Policies and Procedures – This section allows states to adopt other plan flexibilities but only if such changes do not restrict or limit payment, services, or eligibility, or otherwise burden beneficiaries and providers. It is recommended that states consult with CMS on additional policies and procedures to be implemented during the emergency period prior to submitting the disaster relief SPA.

The Medicaid Disaster Relief SPA template is especially helpful in that it highlights proactive steps that Medicaid agencies should consider during this national emergency. CMS also has posted an example of a CHIP Disaster Relief State Plan Amendment although it is not as detailed as the Medicaid template. It mentions temporary adjustments to enrollment and redetermination polices and cost-sharing requirements, and provides an example of how the state CHIP plan that might be amended. We commend CMS for getting these materials, along with a growing list of FAQs and other guidance, out quickly for states and stakeholders to assess what more can be done to promote enrollment and continuity of coverage during this public health crisis.

[See CCF’s waiver and SPA tracker for more information.]

Tricia Brooks is a Research Professor at the Center for Children and Families (CCF), part of the McCourt School of Public Policy at Georgetown University.