Since the start of the COVID-19 pandemic, states have been utilizing Medicaid and CHIP disaster state plan amendments (SPAs) for temporary, additional flexibilities to respond to the challenges resulting from the pandemic. As the administration considers when to end the federally declared Public Health Emergency (PHE), states and stakeholders should think about how to continue some of these beneficial changes, which have lessened red tape and increased access to care for individuals enrolled on Medicaid and CHIP, beyond the PHE.
In March 2020, CMS quickly created a template for COVID-related Medicaid disaster state plan amendments (SPAs) to make it easier for states to make changes to enrollment, premiums and cost-sharing, benefits, and payments, among others. (The agency also allowed changes to be made through CHIP disaster SPAs, but a standard template was not provided). Almost two years later, CMS has approved over 300 disaster SPAs for Medicaid and CHIP covering every state and D.C.
States have continued submitting, and CMS has continued approving, disaster SPAs (mostly for Medicaid) as recently as last week. Recent approvals have predominately been for benefit changes such as adding qualified providers to administer COVID vaccinations as well as payment changes like increasing reimbursement rates for services or providing supplemental payments to providers. These have been a shift from initial disaster SPAs, which were largely focused on reducing burdens on beneficiaries.
Approved disaster SPAs include important protections and/or beneficial changes for enrollees. For example, states have used these authorities to suspend premiums and cost-sharing as well as premium lock-out policies for some or all beneficiaries in Medicaid and CHIP. (See the table below for the states that have waived these policies through newly approved disaster SPAs). As my colleague Tricia Brooks has noted, the methods of suspending CHIP premiums has varied by state.
Table 1. Premium and Cost-Sharing Changes Through Disaster SPAs
| Flexibility | States with approved Medicaid disaster SPAs | States with approved CHIP disaster SPAs |
| Suspend premiums or enrollment fees for all groups | AZ, DE, IA, IL, ME, MD, WV | AZ, DE, GA, IA, IN, IL, KS, ME, MA1, MO, NV, NJ, NY2, NC, PA3, UT, WA, WV, WI |
| Suspend premiums or enrollment fees for specified groups | AK, CA, CO, ID, NE, NC, ND, WI, WY | CO |
| Waive outstanding premiums or premium balances | DE, GA, IN, IL, KS, LA, MA1, NJ | |
| Suspend premium lock-out policies | AZ, ID, IA, IN, KS, LA, MA, ME, MO, NV, NJ, PA, UT, WA, WI | |
| Reduce premium amounts | ID, MO | |
| Waive copayments/cost-sharing for all services or groups | AL, AZ, DE, FL, GA, ID, IA, KY, LA, MO, NE, WV4 | GA, ID, IN, IA, IL, MT, VA, WV |
| Waive copayments/cost-sharing for some services including COVID-related testing and treatment | AK, AR, CA, CO, KS, ME, MD, MA, MI, MN, MS, NH, NC, OH, OK, PA, SD, UT, VT | AL, AR, CO, CT, MS, NJ, NC, PA, TN, UT, WI, WY |
1 For those who apply for a hardship waiver
2 Premiums may be temporarily forgiven/waived OR families may be given additional time to pay
3 Premium due dates may be temporarily extended
4 Excludes drugs unrelated to treatment of COVID-19
Additionally, many states have used disaster SPAs to allow greater use of telehealth for delivering services. Newly added telehealth flexibilities have included allowing services to be delivered through “audio only” communication via telephone, removing face-to-face requirements for providing certain services, and allowing all Medicaid-covered services to be provided through telecommunication. In the first months of the pandemic, CMS released a toolkit on telehealth, which provided states with a number of considerations of how they might want to expand their telehealth flexibilities in Medicaid and CHIP. States have used disaster SPAs to make changes to telehealth in all four domain considerations detailed in the toolkit (populations, services being delivered, providers, and technology used).
The authorities approved through disaster SPAs are tied to the end of the Secretary-declared PHE (or an earlier date selected by the state). Secretary Becerra recently extended the PHE so disaster SPAs flexibilities will be in place through April 16, 2022, pending any further extension. However, once the PHE ends, these authorities will end as well, changing state Medicaid program operations and benefits and protections for enrollees literally overnight. To help mitigate these sudden changes, states can continue some temporary authorities through a regular state plan amendment. For example, states can eliminate premiums, lock-outs, and waiting lists from their CHIP programs for good. Many of the telehealth flexibilities currently in place were available to states prior to the PHE and can also be extended long term; submitting additional SPAs may not be necessary in certain circumstances.
It is worth noting that disaster SPAs allowed states to get around the normal SPA submission process, such as modifying the timelines for tribal consultation and waiving public notice requirements. Therefore, states should begin the process of submitting regular state plan amendments before the end of the PHE for any authorities they wish to continue to ensure timely implementation.
States’ preparations for the end of the PHE have been (rightfully) focused on the unwinding of the continuous eligibility requirement. As states continue to make plans though, they should also consider making authorities permanent where they have the ability to do so, which would reduce burdens to coverage and improve access to care over the long term.
