CMS Issues Covid-19 FAQ
The Centers for Medicare & Medicaid Services (CMS) has posted Frequently Asked Questions (FAQs) to the Medicaid.gov website to aid state Medicaid and Children’s Health Insurance Program (CHIP) agencies in their response to the 2019 Novel Coronavirus (COVID-19) outbreak. CMS has invited states to submit questions to CMS through their state leads, which CMS has used to formulate this first set of FAQs.
The FAQs cover a range of topics and issues that reflect questions and concerns raised by state Medicaid and CHIP agencies. The information highlights the resources available to states, such as the Disaster Preparedness Toolkit developed by CMS specifically for state Medicaid and CHIP agencies, to address a variety of policy and program topics related to eligibility and enrollment, benefits and cost sharing, healthcare workforce, and telehealth. As questions and issues continue to come into CMS, they will be addressed and answered, and added to these FAQs.
One of the very first questions in the document addresses Appendix K of the 1915 (c) waiver application. CMS developed Appendix K of the section 1915(c) waiver application for use by states during emergencies. It describes actions states can take under existing section 1915(c) HCBS waiver authority to respond to an emergency. The appendix may be approved retroactively, as needed, to the date of the event. A completed Appendix K must be submitted for each affected waiver and should be used to advise CMS of expected changes to state waiver operations. Changes may include:
- establishing a hotline,
- increasing the number of individuals served under a waiver,
- creating an emergency person-centered service plan,
- expanding provider qualifications,
- increasing the pool of providers who can render services,
- instituting or expanding opportunities for self-direction,
- and/or permitting payment to HCBS providers when an individual is in a short term hospital or institutional stay.
- temporarily increasing individual eligibility cost limits
- modifying service, scope, or coverage requirements,
- exceeding service limitations,
- adding services to the waiver,
- providing services in out-of-state settings, and/or
- permitting payment for services rendered by family caregivers or legally responsible individuals.
A state or territory may not include changes in Appendix K that are not permitted by statute, such as the inclusion of room and board costs in non-institutional settings. Appendix K instructions and a template can be found at https://www.medicaid.gov/medicaid/home-community-based-services/downloads/1915cappendix-k-instructions.pdf and https://www.medicaid.gov/medicaid/home-community-basedservices/downloads/1915c-appendix-k-template.pdf.
CMS also mentions Appendix K in a discussion of strategies for providing Medicaid services to individuals who are quarantined. Through a 1915(c) Appendix K, if a Medicaid beneficiary already meeting an institutional level of care is quarantined in the community, states could add Live in Caregiver as a service, authorizing family members as providers; home delivered meals could be added to provide one meal per day to the individual; and additional services, such as private duty nursing, could also be added and payment rates could be increased to account for increased health risk to providers and to solicit a larger provider pool.
If a service is tied to a specific setting, the service can be amended either through the state plan or through the Appendix K for 1915(c) programs.. For benefits with federal requirements governing location, such as benefits that require services to be provided in a home and community based setting, CMS says it is available to provide technical assistance related to how states can comply with federal requirements in emergencies. For individuals quarantined in institutional settings, regulations already require that nursing facilities (NFs) and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIDs) have an infection control policy, including policies for prevention, surveillance, and isolation.
CMS also points out that states have broad flexibility to cover telehealth through Medicaid, including the methods of communication (such as telephonic, video technology commonly available on smart phones and other devices) to use. With regard to 1915(i) face-to-face assessments, the use of telemedicine or other information technology medium is authorized under federal regulations at 42 C.F.R. § 441.720 under certain conditions. With regard to 1915(c) waivers, the state can complete an Appendix K to allow case management to be done via telephone or other information technology medium and, where personal care services only require verbal cueing and/or instruction, the personal care service can be expanded to permit information technology medium as a resource.
The FAQ also addresses funding for additional information technology needs during emergencies. First, CMS clarifies that when expenses are expected to fall below minimum thresholds, prior approval may not be required for expenditures to receive enhanced FFP for state IT systems. The document further indicates that FFP for IT systems can be provided in emergencies. The FFP request should include: (1) A brief description of the equipment and/or services to be acquired and an estimate of their costs; and (2) a brief description of the circumstances driving the state's need and the harm that will be caused if the state does not immediately acquire the requested equipment and/or services. FFP approved under this authority would be available from the date the state actually acquires the equipment and services.
A section of the FAQ addresses workforce flexibilities. To address provider shortages for individuals receiving 1915(c) waiver services, states can use Appendix K to expand provider qualifications (e.g., where a provider must be 21 years old, states could modify the age requirement to 18); add additional providers (including allowance of payment to family members and legally responsible relatives); add services, such as a live-in care giver; and temporarily adjust rates to entice more individuals into the workforce. For state plan services, a SPA can increase the types of providers a state authorizes to deliver services. As always, CMS cautions, “states should be mindful of state-level requirements that might impact provider flexibility in delegation of authority.”
FMI: The COVID-19 FAQs for State Medicaid and CHIP agencies can be found here: https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/covid19/index.html