How Can Medicaid Enhance State Capacity to Respond to COVID-19?

Table 1: Medicaid 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
  • Exempt enrollees from premiums
  • 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
  • Treat Federally facilitated Marketplace assessments as eligibility determinations or fully delegate eligibility determination authority to Federally facilitated Marketplace
  • Expand application processing times
  • 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
Amended/Updated Verification Plan – No CMS Approval Required
  • Accept self-attestation and conduct post-enrollment verification for eligibility criteria other than citizenship and immigration status (beyond case-by-case basis)
  • Adopt or increase reasonable compatibility thresholds for income inconsistencies
  • Allow reasonable explanation of inconsistencies in lieu of paper documentation
  • Temporarily suspend periodic data checks (beyond case-by-case basis)
State Plan Amendment – Can be Retroactive to 1st Day of Quarter

  • Increase financial eligibility thresholds (e.g., adopt ACA expansion, cover nonelderly MAGI group above 138% FPL)
  • Cover non-residents or state-defined subset of non-residents such as those living temporarily in state due to disaster in home state
  • Apply host state’s asset limit, or if less restrictive, asset limit from state where individual evacuated (if statewide rule)
Enrollment & Renewal:
  • Adopt or extend presumptive eligibility for certain populations
  • Extend hospital presumptive eligibility to non-MAGI groups
  • Establish state as presumptive eligibility qualified entity to enroll individuals based on preliminary application information
  • Provide 12-month continuous eligibility for children
  • Develop simplified paper application for affected areas
  • Extend reasonable opportunity period to provide documentation for immigration status
  • Temporarily modify copayment requirements to support access to services (if rule applies statewide)
  • Offer additional benefits (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

  • Increase eligibility limits for specific categories in specific geographic regions

Enrollment & Renewal:

  • Provide 12-month continuous eligibility for adults or for a subset of children
  • Allow self-attestation for citizenship and immigration status if unable to verify by data sources and individual unable to document due to disaster


  • Provide benefits to targeted group of enrollees impacted by disaster
  • Temporarily modify copayment requirements to support access to services (less than statewide)
  • Authorize off-island coverage for those in territories eligible for FEMA transitional shelter assistance who are temporarily relocated to a state

Long-Term Services and Supports:

  • 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

  • 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


  • Allow direct access to fair hearing without first exhausting managed care appeal
  • Extend timeframes for individuals to request managed care appeals or state fair hearings
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

  •  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


  • 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


  • 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

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