COVID-19 Issues and Medicaid Policy Options for People Who Need Long-Term Services and Supports

Appendix Table 1: LTSS Users by State and Setting or Authority
State Certified Nursing Facility Residents Assisted Living Facilities ICF/IDD Home health Personal Care Services Community First Choice 1915 (i) 1915 (c) Waiver 1115 waiver PACE
Alabama 22,500 6,100 20 5,900 15,100 170
Alaska 600 1,900 <10 300 3,700 4,300
Arizona 11,300 20,330 140 Included in 1115 52,400
Arkansas 17,400 5,300 1,440 5,000 13,700 15,500 290
California 101,000 106,300 7,820 37,500 273,800 228,200 55,800 149,500 474,300 7,690
Colorado 16,100 12,700 170 23,500 100 46,300 4,440
Connecticut 22,700 1,600 430 30,700 3,200 600 28,300
Delaware 4,200 1,600 100 14,000 400 1,200 6,900 250
DC 2,400 320 8,600 6,000 200 6,900
Florida 72,700 70,500 2,710 20,800 3,200 102,500 2,180
Georgia 33,000 22,600 280 6,200 42,600
Hawaii 3,500 2,390 80 Included in 1115 2,900 8,500
Idaho 3,300 6,500 490 1,900 8,500 4,000 20,200
Illinois 66,600 28,600 6,620 14,400 161,600
Indiana 38,700 15,600 3,250 16,300 4,700 49,100 440
Iowa 23,600 1,500 2,010 12,400 7,100 30,400 560
Kansas 14,700 13,500 450 3,300 Included in 1115 28,700 520
Kentucky 22,800 10,100 430 15,400 24,300
Louisiana 26,200 5,200 4,960 6,600 14,200 20,600 460
Maine 5,900 5,800 160 1,900 3,300 7,500
Maryland 24,400 17,100 4,000 1,000 13,500 25,800 150
Massachusetts 38,700 14,900 410 52,200 45,000 30,600 4,690
Michigan 38,100 26,200 3,300 60,700 24,700 3,290
Minnesota 24,800 29,700 1,590 28,900 43,700 81,500
Mississippi 16,000 5,100 1,610 1,400 700 25,800
Missouri 37,900 11,700 440 4,100 65,600 33,900
Montana 4,200 5,000 40 600 500 3,400 5,700
Nebraska 11,400 7,700 390 200 3,800 11,800 200
Nevada 5,300 5,300 90 1,300 10,300 200 5,700
New Hampshire 6,400 4,000 30 1,400 100 9,200
New Jersey 44,000 17,200 1,880 50,300 49,500 10,700 25,000
New Mexico 5,700 3,700 260 4,000 Included in 1115 5,100 28,000 400
New York 101,500 29,500 5,560 101,400 116,200 NR 98,000 NR 5,170
North Carolina 35,800 26,500 3,160 9,900 44,700 25,300 2,120
North Dakota 5,500 4,700 460 1,100 1,300 5,800 180
Ohio 73,800 33,900 6,150 26,900 7,000 111,400 490
Oklahoma 18,400 7,500 3,600 3,800 26,200 540
Oregon 7,300 23,700 300 3,100 36,500 64,200 1,540
Pennsylvania 76,700 43,200 2,990 26,300 119,700 7,060
Rhode Island 7,800 3,100 40 8,800 400 5,500 320
South Carolina 17,000 9,000 1,170 500 35,200 430
South Dakota 6,000 3,800 190 11,200 1,600 5,900
Tennessee 26,500 13,300 940 11,200 7,800 17,500 260
Texas 92,300 32,300 7,890 11,600 369,700 30,000 200 48,100 68,800 1,140
Utah 5,200 6,300 200 3,100 200 9,300
Vermont 2,400 2,500 <10 3,700 1,400 10,600
Virginia 27,600 17,900 470 1,600 51,300 1,400
Washington 16,000 36,200 750 4,600 1,200 77,900 64,500 1,000 840
West Virginia 9,300 2,752 510 8,100 5,700 10,900
Wisconsin 24,200 28,400 790 5,900 17,900 89,900 540
Wyoming 2,400 1,000 70 400 5,300 130
US TOTAL 1,321,700 811,300 74,610 616,800 1,173,900 392,700 81,000 1,806,600 698,500 47,870
NOTES: Data reported ranges from FY 2016 – 2020, based on availability. Enrollment cannot be compared between populations due to different data sources and time periods. Enrollment cannot be summed across settings due to unknown duplication. Blanks mean the state does not serve that population or they did not report data for that year. Assisted Living Facility enrollment also includes other Residential Care Community enrollment.
SOURCES: KFF analysis of FY 2017 CASPER data (nursing facility residents), National Study of Long-Term Care Providers (residential care community residents), University of Minnesota, Institute on Community Integration (ICF/IDD residents), KFF Medicaid HCBS Program Survey, FY 2018 (HCBS enrollment), and February 2020 PACE Enrollment from Integrated Care Resource Center.
Appendix Table 2: Medicaid LTSS Authorities Available in Emergencies
Allowed by Existing Regulations
  • Allow self-attestation to verify eligibility for all criteria except citizenship and immigration status on a case-by-case basis; verify assets if financial institution unable to verify due to disaster; verify incurred medical expenses for spend down eligibility
  • Extend renewal timeframes
  • Temporarily suspend periodic data checks on case-by-case basis
  • Temporarily delay acting on certain changes in circumstances affecting eligibility
  • Reinstate services or eligibility if discontinued because whereabouts unknown due to evacuation, after whereabouts become known and if still eligible
  • Consider people evacuated from state as temporarily absent to maintain enrollment
  • Suspend adverse actions for those in disaster area where state has completed determination but has not yet sent notice or state believes notice likely not received
  • Temporarily increase HCBS waiver service payment rates if no change to rate methodology and no impact on cost neutrality
State Plan Amendment – Can be Retroactive to 1st Day of Quarter, and to 1/1/20, using Section 1135 authority
Coverage:

  • Apply host state’s asset limit, or if less restrictive, asset limit from state where individual evacuated (if statewide rule)

Enrollment::

  • Extend hospital presumptive eligibility to non-MAGI groups

Benefits:

  • Offer additional benefits, such as state plan HCBS (if comparable for all categorically needy groups and statewide with free choice of provider, or via alternative benefit plan with free choice of provider)
  • Change amount, duration, or scope of covered benefits
  • Amend payment methodology to account for increased cost of personal protective equipment for home care workers
Health Plan Contract/Oversight
  • Temporarily suspend out of network requirements for managed care enrollees
  • Require health plans to expedite processing of new prior authorization requests and allow flexibility in documentation (e.g., physician signature)
Section 1115 Waiver – state is deemed to meet budget neutrality if federally declared disaster, waiver can be retroactive to date of Secretary-declared public health emergency, exemptions from public notice in emergencies
  • Temporarily suspend requirement to be institutionalized at least 30 days and have income below 300% SSI to be eligible for special income group
  • Temporarily suspend asset transfer rules for those placed in nursing homes
  • Apply host state’s asset limit, or if less restrictive, asset limit from state where individual evacuated (if less than statewide)
  • Do not reduce institutional provider payments by post-eligibility treatment of income
Section 1135 Waiver – if President declares national emergency and HHS Secretary declares public health emergency
Benefits:

  • Temporarily suspend fee-for-service prior authorization requirements and/or require providers to extend prior authorization through the termination of emergency declaration
  • Covered Providers:
  • Temporarily waive requirements for out-of-state providers to be licensed in state where they are providing services if provider is licensed by another state Medicaid agency or Medicare
  • Temporarily waive provider screening requirements, such as application fees, criminal background checks, and site visits, to ensure sufficient number of providers
  • Temporarily cease revalidation of providers in state or who are otherwise directly impacted by disaster
  • Temporarily suspend pending enforcement or termination actions or payment denial sanction to specific provider
  • Allow facilities to provide services in alternative settings such as temporary shelters when provider facility is inaccessible
  • Temporarily allow non-emergency ambulance providers
Long-Term Services and Supports:
  • Provide nursing home care to evacuees in host state for less than 30 days if individual is Medicaid-eligible in home state
  • Temporarily suspend pre-admission screening and annual resident review assessments for 30 days
  • Extend minimum data set authorizations for nursing home and skilled nursing facility residents
  • Temporarily suspend requirement that home health agency aides be supervised for 2 weeks by registered nurse
  • Temporarily suspend requirement that hospice aides be supervised by registered nurse every 14 days
  • Modify or suspend certain state survey agency activities
Section 1915 (c) Home and Community-based Services Waiver Appendix K – can be submitted before or during emergency, can be retroactive to date of event
Eligibility:

  • Increase number of unduplicated waiver enrollees
  • Temporarily increase individual cost limit to assure health and welfare
  • Modify eligibility targeting criteria to serve more enrollees and forestall institutionalization in emergency
  • Extend level of care authorizations for 12 months

Benefits:

  • Add covered services not expressly authorized in statute if necessary to assist waiver enrollees to avoid institutionalization
  • Modify scope of covered services and temporarily exceed individual service limits to ensure health and welfare
  • Institute or expand self-direction
  • Temporarily suspend prior authorization and extend medical necessity authorizations
  • Modify person-centered planning process, including qualifications of individuals required to develop plan

Providers:

  • Temporarily increase payment rates with a temporary change in rate methodology and/or impact on cost neutrality
  • Amend payment methodology to account for increased cost of personal protective equipment for home care workers
  • Allow payment for services provided by family caregivers or legally responsible relatives
  • Temporarily modify provider types, qualifications, and licensure or other setting requirements
  • Include retainer payments to personal care assistants when waiver enrollee is hospitalized or absent from home up to 30 days
  • Expand covered settings to include out-of-state
  • Temporarily allow payment for waiver services up to 30 days to support enrollees in acute care hospital or short-term institutional stay when services are required for communication and behavioral stabilization and not provided by institution
SOURCES: CMS, COVID-19 Frequently Asked Questions for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies (March 12, 2020); Medicaid and CHIP Coverage Learning Collaborative, Disaster Preparedness Toolkit for State Medicaid Agencies (Aug. 20, 2018); Medicaid and CHIP Coverage Learning Collaborative, Inventory of Medicaid and CHIP Flexibilities and Authorities in the Event of a Disaster (Aug. 20, 2018); CMS, 1915 (c) Home and Community-Based Services Waiver Instructions and Technical Guidance

APPENDIX K: Emergency Preparedness and Response.

Issue Brief

The Henry J. Kaiser Family Foundation Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270

www.kff.org | Email Alerts: kff.org/email | facebook.com/KaiserFamilyFoundation | twitter.com/kff

Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in San Francisco, California.