Medicaid is poised to fill critical healthcare needs amid the COVID-19 crisis. A +15% unemployment rate and the associated widespread loss of employer-provided health insurance benefits could spike its eligibility numbers. As a result, providers not yet enrolled in Medicaid increasingly may find benefits in doing so. The opportunity for providers to enroll in Medicaid also comes as the majority of healthcare organizations struggle financially and attempt to bring patients back following lock downs or partial closures, a switch to telehealth, and suspension of elective procedures and services during the pandemic.
Because Medicaid is a cooperative arrangement between the federal government (which largely subsidizes the program) and states that administer their respective Medicaid programs, practitioners providing Medicaid or Children’s Health Insurance Program (CHIP) services must enroll in, and adhere to, each state’s program. While there are federal guidelines—for example state Medicaid agencies must revalidate the enrollment of all providers, regardless of provider types, at least every five years (42 CFR 455.414)—most administration exists at the state level.
How COVID-19 is affecting Medicaid enrollment
COVID-19 was declared a national emergency on March 13, 2020, enabling the Department of Health & Human Services (HHS), which oversees the Centers for Medicare & Medicaid Services (CMS), to modify elements of all federal healthcare programs and services. Most of the changes CMS made in response to COVID-19 affect Medicare. However, CMS rolled out modifications to Medicaid and CHIP in an effort to eliminate distractions and barriers to front-line providers enrolled in Medicaid (or planning to enroll) and caring for the sickest and most vulnerable patients during the pandemic.
The following areas represent changes to Medicaid administration as a result of the pandemic. As a result, providers already enrolled or considering participation in their state Medicaid or CHIP programs should take note.
Disaster declaration waivers provide flexibility
Whether or not your healthcare organization is in a state that opted into expanded Medicaid coverage following the Affordable Care Act (ACA), there are new relaxed rules—some permanent and others in effect for the short term. In a prepared statement, CMS strongly encouraged states to take advantage of the options available through the disaster-driven waivers, on behalf of enrolled providers and their healthcare organizations. An FAQ document released by CMS provides additional guidance to states on the expanded allowances, which in turn affect providers enrolled in the program.
State Medicaid agencies gain relief on enrollment, other items
To ensure availability of services to beneficiaries and to ease burdens on enrolled providers as they furnish requirements to participate in Medicaid, provide care and services, and receive reimbursement during the COVID-19 pandemic, CMS is allowing states to request temporary waivers under Section 1135 of the Social Security Act, outlined in the Medicaid and CHIP Disaster Response Toolkit.
A 1135 Medicaid & CHIP Checklist provided by CMS includes allowances across many areas—from Medicaid authorizations to long-term services and supports, provider enrollment, fair hearings, reporting and oversight, and more.
Specific to provider enrollment, the checklist contains the following temporary options for healthcare organizations with Medicaid-participating providers:
- Waive payment of application fee to temporarily enroll a provider
- Waive criminal background checks associated with temporarily enrolling providers
- Waive site visits to temporarily enroll a provider
- Permit providers located out-of-state/territory to provide care to an emergency state’s Medicaid enrollee and be reimbursed for that service
- Streamline provider enrollment requirements when enrolling providers
- Postpone deadlines for revalidation of providers who are located in the state or otherwise directly impacted by the emergency
- Waive requirements that physicians and other healthcare professionals be licensed in the state in which they are providing services, so long as they have equivalent licensing in another state
- Waive conditions of participation or conditions for coverage for existing providers for facilities for providing services in alternative settings, including using an unlicensed facility, if the provider’s licensed facility has been evacuated
Examples of the relief provided on the checklist for non-enrollment items include:
- Waiver of prior authorization requirements
- Temporary suspension of certain pre-admission and annual screenings for nursing home residents
States that did not opt into Medicaid expansion may do so, potentially expanding provider enrollment opportunities
All states participate in Medicaid on some level. In 2014, the ACA offered states the option to expand their Medicaid programs to cover more low-income beneficiaries using a graduated funding scale. (Households with income below 133% of the federal poverty level qualify.) Today 36 states and the District of Columbia provide such expanded coverage, and Medicaid expansion funding through CMS has topped out at a 90% federal matching rate.
Under the COVID-19 emergency declaration, CMS is offering flexibility to the 14 states that didn’t adopt Medicaid Expansion as part of the ACA. Notably, a recent study showed reduced uninsured rates among unemployed adults in states that expanded Medicaid eligibility under the ACA starting in 2014. Now, experts expect rising unemployment as a result of COVID-19 to more acutely affect states that didn't expand Medicaid. If those states decide to expand Medicaid, it will present new opportunities for providers to enroll.
BHP blueprint revisions are allowed
Within Medicaid, states also may elect to operate a Basic Health Program (BHP) for healthcare coverage of individuals under age 65 with household incomes between 133% and 200% of the federal poverty level who are not eligible for Medicaid, CHIP, or affordable employer-sponsored coverage. This expansion, too, would provide additional opportunity for Medicaid-enrolled providers in BHP-participating states to see additional patients.
CMS recognizes that as a result of the pandemic, states operating a BHP may need to implement immediate yet temporary changes. Under the waiver, a state’s revisions to its BHP blueprint must:
- Be directly tied to the COVID-19 public health emergency
- Increase access to coverage
- Not be restrictive in nature
For example, states may seek to temporarily allow continuous eligibility or waivers of limitations on certain benefits to ensure that enrollees have access to needed services during the crisis. In addition, temporarily revised BHP blueprints aren’t subject to the typical public comment requirements, although they must be HHS-approved. Permanent significant changes to a state’s blueprint must still be submitted under the standard process (42 CFR § 600.125(a)).
Waivers affecting laboratory services
Potential, additional opportunity for Medicaid-enrolled providers also exists in the new Medicaid waivers for labs. The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act added a new mandatory benefit providing Medicaid coverage for COVID-19 detection tests and the administration of the tests. The benefit:
- Gives states flexibility to cover a COVID-19 test under Medicaid without it being first ordered by a physician or other licensed practitioner
- Allows the state Medicaid benefit to cover COVID-19 tests administered in certain non-office settings that are intended to minimize transmission of COVID-19 (e.g., parking lots)
- Allows Medicaid to cover laboratory processing of self-collected COVID-19 tests that the FDA has authorized for home use.
Beyond COVID-10, this new mandatory benefit will be available for any future public health emergency that results from outbreaks of communicable disease where measures are needed to avoid transmission and where there might otherwise be difficulty in meeting requirements of the rule.
Revisions affect home health benefits
Expanded opportunity for nonphysicians enrolled in Medicaid exists in waivers related to home health, following the pandemic. The CARES Act permanently modifies Medicare and Medicaid home health benefits (42 CFR 440.70) by updating which practitioners can order the benefits. While the revisions don’t change the scope of services authorized under the new mandatory home health benefit, they now allow Medicaid-enrolled nurse practitioners, physician assistants, and clinical nurse specialists to order home health services. Previously, only physicians could order the service. The reasoning behind the change is threefold:
- It reflects CMS’ recognition of the expanded scopes of nonphysicians
- It expands the provider pool to serve the immediate, acute needs of the pandemic
- It modernizes the Medicaid mandatory benefit and brings durable medical equipment (DME) for Medicaid in line with that of Medicare
Regarding DME: The CARES Act amended both Medicare and Medicaid home health benefits, but there are differences between the programs’ DME offerings. Various providers (in addition to physicians) could order DME under Medicare. Medicaid, however, doesn’t contain a separate DME benefit and thus was more restrictive on who could order medical supplies (wheelchairs, hospital beds, canes, ventilators, etc.). This update brings Medicaid in line with Medicare regarding DME ordering capabilities among providers.
COVID-19 related funding for CMS-enrolled providers
Recent federal legislation has also created new funding opportunities for states and providers responding to the COVID-19 crisis.
The FFCRA, effective April 1, 2020 through December 31, 2020, primarily affects US businesses and aims to protect employees’ health insurance coverage during the pandemic. Regarding states’ Medicaid, it provides an estimated $36 billion in additional funding. To qualify, states must agree to help protect people’s access to healthcare coverage and are barred from ending individual’s Medicaid coverage during the pandemic, with exceptions for voluntary relinquishment and moves out of state. Lastly, it makes available a new optional “COVID-19 Testing” Medicaid eligibility group.
On April 24, 2020, the Paycheck Protection Program and Health Care Enhancement Act and CARES Act (including CARES 3.5 Act) was signed into law. In part, it established a relief fund to directly reimburse Medicare or Medicaid enrolled providers (and for-profit or nonprofit entities) for expenses/lost revenues attributable to COVID-19 and not otherwise reimbursable.
To date, distributions from the provider relief fund have mainly gone to Medicare providers based on their historic net revenue. So far, HHS, which oversees the program, hasn’t set aside specific funds for enrolled providers predominantly serving Medicaid/uninsured patients and hasn’t yet funneled resources to providers with the greatest COVID-19-driven monetary needs. It’s currently left up to individual states, as administrators of their Medicaid programs, to ensure funds are available for Medicaid providers.
The Payer Enrollment Services team at symplrCVO specializes in enrolling your applicants into federal, state, and commercial payer insurance plans. The result: Faster reimbursement for the care and services your practitioners deliver.
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