Disaster relief state plan amendments

During emergencies or disasters, states may use options available under Medicaid and State Children’s Health Insurance Program (CHIP) state plan authority to make a number of temporary program changes. States can submit Medicaid disaster relief state plan amendments (SPAs) to simplify the beneficiary enrollment and renewal process such as expanding use of presumptive eligibility to expedite enrollment during an emergency or disaster or suspending redeterminations to minimize churn and ensure continuity of health care in light of a public health crisis (Boozang and Serafi 2020). States may also temporarily modify cost sharing and premium requirements, benefits, and provider payments. States may also make changes using the regular SPA process if they want to make permanent changes.

States may also submit CHIP SPAs that allow for temporary changes to enrollment, redetermination, and cost-sharing policies during a disaster. These changes can only be applicable for individuals living or working in a disaster area, as declared by a governor or FEMA, or in cases of a national emergency (MACPAC 2018). Once states’ CHIP state plans include provisions for temporary emergency changes, if future emergencies occur, states may notify the Centers for Medicare & Medicaid Services (CMS) of their intent to invoke the flexibilities and do not have to submit another SPA.

In an emergency, states may use Section 1135 waiver authority to seek flexibility related to public notice, and to modify the tribal consultation timeline, and timing of Medicaid and CHIP SPA submissions relative to the effective date for SPAs that increase beneficiary access to COVID-related services and do not restrict or limit payment, services, eligibility, or otherwise burden beneficiaries and providers (CMS 2020).

Medicaid COVID-19 disaster relief SPAs

In response to the COVID-19 pandemic CMS issued a Medicaid disaster relief SPA template and instructions to facilitate state completion and submission of requests. The template and instructions describe changes that can be in response to the COVID-19 pandemic in the areas of eligibility, enrollment, premiums and cost sharing, benefits, payment, and post eligibility treatment of income. COVID-19 Medicaid disaster relief SPAs are in effect from March 1, 2020 through the end of the public health emergency, including any extensions, unless the state specifies different dates within that period (CMS 2020). As of May 21, 31 states had approved Medicaid SPAs including several states with multiple approved SPAs.

TABLE 1. Overview of Selected Approved COVID-19 Medicaid Disaster Relief SPAs, as of May 21, 2020

Medicaid state plan flexibility	States
Eligibility
Coverage of COVID-related testing and treatment for uninsured individuals, regardless of income or resources	Arizona, California, Colorado, Illinois, Iowa, Louisiana, Maine, Minnesota, Montana, New Mexico, Rhode Island, South Carolina, Utah, and Washington
Apply less restrictive financial methodologies to non-modified adjusted gross income populations	Illinois, Tennessee, and Washington
Consider individual absent from state due to public health emergency as resident	Iowa, Louisiana, Maine, Nebraska, Rhode Island, and Washington
Coverage of non-state residents	Alabama and Washington
Extension of reasonable opportunity period for noncitizens	Alaska, Louisiana, Nebraska, and Rhode Island
Enrollment
Hospital presumptive eligibility for additional populations	California, Iowa, Kansas, New Mexico, Utah, Washington, and Wisconsin
State Medicaid agency to conduct presumptive eligibility	Illinois and Kansas
Addition of qualified entities or populations subject to presumptive eligibility	Illinois, Kansas, Nebraska, and New Mexico
Adoption of continuous eligibility for children	Arizona, Missouri, Oklahoma, and Rhode Island
Changes to frequency of redeterminations to non-MAGI populations	None
Use of simplified applications	None
Premiums and cost sharing
Suspend out-of-pocket cost sharing	For all beneficiaries or services: Arizona, Georgia, Iowa, Louisiana; for Maine, most services For COVID-related testing and treatment services: Alabama, Alaska, Arkansas, California, Colorado, Kansas, Maryland, Minnesota, Missouri, New Mexico, Oklahoma, and Utah
Suspend premiums, enrollment fees	For all beneficiaries: Arizona, Iowa, Maine, and Washington For specified beneficiaries: Alaska, California, Colorado, Illinois, Maryland, Minnesota, North Carolina, North Dakota, and Wyoming
Waive premiums, enrollment fees for undue hardship	Missouri
Benefits
Add optional benefits	Colorado (pharmacist-ordered and administered COVID-19 tests) Iowa (certain 1915(i) HCBS services) Maine (any COVID-19 test) Oklahoma (crisis intervention services by independently contracted psychologists) Rhode Island (emergency case management for certain high-risk populations at risk for COVID-19) Washington (some dental and pharmacy services)
Changes to benefits	Alabama (lifts restrictions on emergency ambulance destinations and eliminates prior authorization for non-emergency services) Alaska (allows personal care services to be provided in an acute care hospital; allows students who have completed all coursework to practice as unlicensed mental health professionals and pharmacists to practice at the top of their license) Arizona (allows non-physician practitioners to order home health care) Arkansas (clarifies coverage of E&M services for certain adults with serious mental illness and wellness checks for individuals with developmental disabilities and delays; and exempts most providers from the 12 visit per year limit when the visit is associated with COVID-19) California (covers non-physician ordered home health; makes changes to rehabilitative services) Colorado (increases the total number of targeted case management services allowed; covers non-physician ordered home health; makes changes to NEMT) Iowa (permits expansion of HCBS services) Louisiana (extends prior authorizations for certain services; relaxes long-term personal care service restrictions) Maryland (allows licensed practitioners to order home health services; expands remote patient monitoring; allows family members to perform Community First Choice Services & Supports) Washington (covers non-physician ordered home health care)
Application of benefit changes to alternative benefit plans	Alaska, Colorado, Louisiana, Maine, Maryland, and Washington
Changes to telehealth	Alabama, Illinois, Louisiana, Maine, Maryland, Minnesota, Mississippi, Montana, Nebraska, Oregon, and Washington
Drug benefit: supply or quantity limits	Alaska, Kansas, Minnesota, Montana, North Dakota, and Oklahoma
Drug benefit: automatic renewal	Arizona, Illinois, Kansas, Louisiana, Montana, North Dakota, Oklahoma, and Rhode Island
Drug benefit: dispensing fees	Alaska and Kansas
Drug benefit: exceptions to preferred drug list in the event of a shortage	Alaska, Arizona, Illinois, Kansas, Louisiana, Maine, Missouri, Montana, North Dakota, Rhode Island, and Washington
Payment
Increased payment for certain services	Alabama (increases per diem and cleaning payments to nursing facilities) Alaska (modifies payment of Targeted Case Management Infant Learning Program and LTSS) Arkansas (increases rates for LTSS) Colorado (increases payment rates to nursing facilities and ICF/IIDs by 8 percent) Illinois (increases per diem rate by 20 percent for certain services to beneficiaries who are medically complex or developmentally disabled) Kentucky (adds a supplement to nursing facility per diem for each resident with COVID-19) Louisiana (increases rates for certain nursing facilities, extends leave of absence pay to ICF/IIDs, pays ambulance providers for on-site services) Maine (increases rates for substance abuse treatment facilities and child care facilities, creates a $10 million supplemental pool for acute care hospitals) Montana (adds $40 per day per member to skilled nursing and intermediate care services) New Mexico (increases rates for inpatient services, advances distribution of DSH payments) Oregon (adds new telehealth rates to fee schedule) Washington (provides supplemental payment for COVID-related transportation services)
Telehealth payment policies	Arkansas, Illinois, Maine, Mississippi, Nebraska, Oregon, and Washington
Other payment	Arkansas (sets rates for COVID-19 services) Colorado (adds new policy for payment to unlicensed nursing facility workers performing healthcare tasks during the emergency) Hawaii (sets bed hold maximum at 24 days per year) Maryland (permits payment of NEMT) Nebraska (adds new codes and rates associated with COVID-19) Oklahoma (allows providers to receive an interim of up to two months’ average payment, increases hourly pay to private duty nursing providers) Washington (unbundles billing codes for transferring specimens from patients to labs)
Post-eligibility treatment of income
Basic personal needs allowance for institutionalized individuals	Rhode Island (extends the home maintenance of need allowance to certain institutionalized individuals who demonstrate a greater need due to COVID-19)
Other
	Arizona (increases nursing facility bed hold to 30 days per year) Colorado (must demonstrate that nursing facility payments do not exceed the fee-for-service-upper payment limit) Kentucky (increases nursing facility bed hold to 30 days per year) North Dakota (waives the timeline for nursing facility rate reconsiderations and appeals and the 15-day limit for reserve bed payments for COVID-related hospitalizations) Oklahoma (waives penalties for potentially preventable readmissions program; increases nursing facility bed hold days to 10 and ICF/IID bed hold to 70 days) Oregon (allows verbal approval and e-signatures for person-centered service planning and delivery)

Notes: E&M is evaluation and management. NEMT is nonemergency medical transportation. HCBS is home and community-based services. LTSS is long-term services and supports. ICF/IID is intermediate care facilities for individuals with intellectual disabilities. Table is current as of May 21, 2020.
Source: MACPAC analysis of approved state Medicaid disaster relief state plan amendments.

For the most up to date information on approved state Medicaid disaster relief SPAs, see CMS’s Medicaid State Plan Amendments webpage.

CHIP COVID-19 disaster relief SPAs

States also are making temporary CHIP program changes in response to COVID-19. To do so, states must submit a CHIP disaster relief SPA describing the changes being made with respect to eligibility and enrollment, and cost sharing and premiums. CHIP disaster relief SPAs related to COVID-19 can take effect from the start of the state or federal emergency declaration through the end of the public health emergency including any extensions (CMS 2020). As of May 21, 13 states had approved CHIP disaster SPAs.

TABLE 2. Overview of Selected Approved COVID-19 CHIP Disaster Relief SPAs, as of May 21, 2020

CHIP state plan flexibility	States
Eligibility and Enrollment
Delay acting on circumstances affecting eligibility, delay renewals	Arizona, California, Georgia, Iowa, Kansas, Louisiana, Nebraska, North Carolina, Pennsylvania, Rhode Island, Tennessee, Virginia, and Wyoming
Temporarily provide continuous eligibility (CE)	Arizona, Nebraska (extend approved CE period through end of pregnancy)
Temporarily provide presumptive eligibility (PE)	Kansas (allow for two periods PE periods within a 12-month period) and Nebraska
Waive timely processing of applications and renewals	Arizona, Georgia, Iowa, Kansas, Maine, North Carolina, Nebraska, Pennsylvania, Rhode Island, Tennessee, Virginia, and Wyoming
Provide families additional time to submit a renewal or verification information	Arizona, California, Iowa, Louisiana, Maine, North Carolina, Pennsylvania, and Tennessee
Extend reasonable opportunity time to verify immigration status	Kansas, Nebraska, Louisiana, Rhode Island, and Virginia
Waive verifications of eligibility requirements, accept self-attestation	California, Louisiana, and Maine
Waive waiting periods	Arizona
Out-of-pocket costs
Waive cost sharing	Arizona, California (for certain populations), Georgia (for COVID-19 testing effective March18, 2020 and for all services effective May 1, 2020), Iowa¹, Louisiana, North Carolina, Pennsylvania, Tennessee, Virginia, and Wyoming (for COVID-19 testing)
Waive or delay premiums and enrollment fees	Arizona, California (for certain populations), Georgia, Iowa¹, Kansas, Louisiana, Maine, North Carolina, and Pennsylvania
Waive consequences of failure to pay (e.g. waive lock-out period for failure to pay premiums)	Arizona (suspend lock-out period and waive premium balance) California (waive premium balance, extend premium due date) Iowa, Kansas, and Louisiana (suspend lock-out period)¹ Maine (waive lock-out period, premium balance, extend premium due date)
Other
Waive prior authorization requirements	Louisiana and North Carolina

Note: Table is current as of May 21, 2020.
¹Iowa has authority to extend these authorities for a specified time beyond the public health emergency.
Source: MACPAC analysis of approved state CHIP disaster relief state plan amendments.

For the most up to date information on approved state CHIP disaster relief SPAs, see CMS’s CHIP State Program Information webpage.