Today, the Centers for Medicare &
Medicaid Services (CMS) posted additional 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 is taking this action in its continuing
efforts to protect the health and safety of providers and patients,
including those who are covered by Medicaid and CHIP.
As we answer new questions, those
responses will be integrated into a comprehensive set of FAQs. The complete
COVID-19 FAQs for State Medicaid and CHIP agencies, including those
previously issued and those released today, can be found here: https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/covid19/index.html
Newly answered questions are
identified as such in the document, and are also included in the body of
this email for easy reference. Additionally, Medicaid and Children’s
Health Insurance Program (CHIP) agencies can send additional questions
directly to the mailbox: MedicaidCOVID19@cms.hhs.gov.
These FAQs, and earlier CMS actions
in response to the COVID-19 virus, are part of the ongoing White House Task
Force efforts. To keep up with the important work CMS is doing in response
to COVID-19, please visit the Current
Emergencies Website. Additionally, CMS has launched a
dedicated, Medicaid.gov,
COVID-19 resource page that will be continually updated with
relevant information.
CMS is available to provide technical
assistance to states to support your needs in responding to the COVID-19
virus. If you have questions or would like technical assistance in
this area, please contact your state lead.
Below are the new FAQs that CMS
posted on Medicaid.gov today:
Emergency Preparedness and Response
What options do states have for obtaining required signatures
on SPA submissions, given that current state telework policies may present
challenges with obtaining signatures?
Federal regulations at 42 C.F.R. § 430.12
set forth requirements for state plan amendments including the format and
when the state plan must be amended. The regulations do not set forth
requirements related to signatures on SPA submissions; as such, states have
flexibility to utilize different options for signatures on the Form
CMS-179, including electronic signature, scanned clearly legible signature,
wet signature, and insertion of /s/. States need to ensure that the
person “signing” is duly authorized to submit SPAs.
Can
states activate their existing CHIP disaster provisions due to a public
health emergency such as COVID-19, or is this type of SPA limited to
geographically localized natural, environmental, and man-made disasters?
Some
states have disaster provisions in their state plan that say that the
provisions may be activated up in “Governor or FEMA declared disaster
areas.” States may activate these disaster provisions in response to the
public health emergency. CMS’s Disaster Preparedness Toolkit gives
examples of natural and human-made disasters such as hurricanes (e.g.,
Hurricanes Katrina, Maria, Harvey and Irma), wildfires (e.g., California
wildfires), flooding (e.g., Hurricane Harvey floods in Texas), and public
health emergencies (e.g., Flint, Michigan lead contamination crisis).
For the purposes of CHIP disaster relief provisions, CMS deems a
significant outbreak of an infectious disease to be a disaster.
To the extent that states have not
yet incorporated disaster relief provisions into their CHIP state plans,
CMS recommends including a federal or Governor declared emergency as events
that can trigger the disaster provisions.
Eligibility and Enrollment Flexibilities
Can states temporarily discontinue
use of their Asset Verification Systems (AVS) or use the AVS
post-enrollment to expedite hospital discharges in the event of a disaster
or public health emergency?
States may not suspend use of their
AVS under the state plan, which is required under sections 1902(a)(71) and
1940 of the Act. However, the statute does not require that states
verify assets using their AVS prior to an initial determination.
Instead, states may initially rely on self-attestation of assets and verify
financial assets using their AVS post-enrollment in Medicaid. 42 CFR
§435.945. Under regulations at 42 C.F.R. § 435.916(d), if a
state obtains new asset information from the AVS post-enrollment that
indicates an individual may not be eligible, the state must evaluate that
information and redetermine eligibility as appropriate. However, we
note that, pursuant to section 6008(b)(3) of the Families First Coronavirus
Response Act (FFCRA), Pub L. No. 116-127 (2020), in order to be eligible for
the temporary 6.2 percent FMAP increase under section 6008(a) of the FFCRA,
states may not terminate an individual, once determined eligible, through
the end of the month in which the public health emergency ends. This
would include any individuals determined eligible for Medicaid based on
self-attested asset information for whom verification using the state’s AVS
is done post-enrollment. See FAQ Question B.7. for additional
information on states’ responsibility to redetermine eligibility whenever
they receive information indicating a beneficiary may no longer satisfy the
criteria for eligibility and for the implications of the FFCRA on this
policy.
States may also be able to help
expedite provision of medical assistance to applicants who must meet a
resource standard as well as enrollment of applicants pending hospital
discharge through extension of hospital presumptive eligibility to
populations excepted from modified adjusted gross income (MAGI)
methodologies. See FAQ Question B.1. for additional information
related to presumptive eligibility.
Can states modify their verification
policies to support ongoing eligibility and enrollment during a disaster or
public health emergency?
States may modify their verification
policies to use attestation for eligibility factors, if permitted under the
statute; to adopt post-eligibility verification; or to change their
reasonable compatibility standard for verification of income. States
can make these changes through an update to their verification plan, or by
submitting an addendum to their verification plan of policies to be in
effect during a public health emergency or other disaster. CMS has developed
a template which states interested in submitting a “disaster relief
addendum” can use, available at https://www.medicaid.gov/medicaid/eligibility/downloads/magi-based-verification-plan-addendum-template.docx.
States submit updated verification plans to CMS, but CMS approval is
not required prior to implementing a change in a state’s verification
processes. For CHIP, states must document in their disaster relief
SPA that they will be temporarily modifying verification procedures.
Can states stop acting on changes in circumstances during the
COVID-19 public health emergency?
States
are required under regulations at 42 C.F.R. § 435.916(d) to promptly
redetermine eligibility whenever they receive information about a change in
circumstances that may impact eligibility. However, CMS recognizes
that the impact of the COVID-19 public health emergency is impacting the
ability of state agencies to process changes in circumstances in a timely
manner, such that what is considered “prompt” under the current
circumstances may be longer than what typically would be expected.
States that are unable to promptly process changes in circumstances that
may impact eligibility are advised to obtain CMS concurrence that the delay
is warranted under the circumstances. States must document the delay
in the beneficiary’s case record.
Alternatively, if a large number of
cases are affected and the state can clearly define the cohort of cases for
which it seeks CMS’ concurrence, CMS will not enforce compliance with the
requirement that states document the delay in each case record included in
the cohort described. States do not need to make a formal request for
CMS concurrence, but may notify via email to the CMS state lead.
Further, in order to qualify for the
increased Federal medical assistance percentage (FMAP) provided under
section 6008(a) of the FFCRA, through the end of the month in which the
public health emergency ends, pursuant to section 6008(b)(3) of the FFCRA,
states may not terminate individuals enrolled for Medicaid benefits as of
March 18, 2020, or determined eligible on or after that date. This
includes continuing coverage for individuals who experience a change in
circumstances that impacts eligibility or are determined eligible based on
self-attestation for certain criteria, if the state has adopted
post-enrollment verification of the criterion. Thus, if a state is
able to process a change in circumstances prior to the end of the month in
which the public health emergency ends, and determines that a beneficiary
no longer meets all eligibility criteria for coverage, the state must
postpone taking adverse action until after the end of the month in which the
emergency ends in order to qualify for the temporary FMAP increase.
See also Families First Coronavirus Response Act – Increased FMAP FAQ B.6,
available at https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-faqs.pdf.
Benefit Flexibilities
Can states waive signature
requirements for beneficiaries to receive their prescription drugs? Must
beneficiaries continue to receive counseling on their medications?
There are currently no federal
Medicaid rules that require beneficiaries to provide their signature in
order to receive prescription drugs. Requirements for signatures are
usually found in a state provider manual and are at the discretion of the
state Medicaid program. Therefore, CMS encourages states to explore
ways to ease state signature requirements in order to allow beneficiaries
to access their medications during the public health emergency.
Pharmacists should follow state laws
regarding counseling patients, which may permit counseling by phone.
How do the Medicaid flexibilities
around use of telehealth as a service delivery mode interact with Medicare
and commercial third party liability (TPL) requirements, which may be less
flexible around telehealth? For example, a Medicare or commercial
payer may require a face-to-face physician visit to order care or supplies.
Please note that Medicare has
recently increased flexibilities related to telehealth due to the public
health emergency, as summarized in the fact sheet available at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.
While Medicare and commercial payers have increased flexibilities for
telehealth, there may still be instances where coordination of benefits is
necessary.
Medicaid payment allows for state
plan flexibilities in the event Medicare or a commercial insurer denies
payment. If the third party denied the claim for a substantive reason
(e.g., service not covered) and the service is covered under the Medicaid
state plan, Medicaid would review for payment accordingly. If at a
later time, the state is made aware of a third party’s coverage for these
specific services, the state, as it currently does, would chase recovery of
payment accordingly. Therefore, in the example above, once Medicare
or a commercial payer reviews a claim and denies for a substantive reason,
such as face-to-face physician visit requirement, Medicaid would review and
pay according to the state plan. If telehealth is permitted under the
Medicaid state plan, Medicaid would pay accordingly.
Can CHIP pay for the caregiver of a CHIP beneficiary to be
tested for COVID-19?
No.
CHIP may only pay for services provided to the covered individual, in
accordance with the CHIP state plan. CHIP covers COVID-19 testing for
enrollees.
Cost-Sharing Flexibilities
Can states suspend Medicaid and CHIP premiums and CHIP premium
lockout requirements for enrollees affected by a disaster or public health
emergency?
Yes. States can suspend
premiums for the duration of the COVID-19 public health emergency.
States can effectuate such a suspension, and other cost-sharing
requirements, for the duration of the COVID-19 public health emergency
through the Medicaid Disaster Relief for the COVID-19 National Emergency
State Plan Amendment template available here https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/state-plan-flexibilities/index.html.
States can also use the Disaster Relief State Plan Amendment to
suspend termination of eligibility for failure to pay premiums.
Even if a state does not suspend Medicaid and CHIP premiums, we
note that in order to be eligible for the temporary FMAP increase under
section 6008 of the Families First Coronavirus Response Act, states cannot
disenroll Medicaid beneficiaries for failure to pay premiums. Section
6008(b)(2) of the FFCRA, as amended by section 3720 of the CARES Act,
places additional restrictions on states’ ability to increase premiums
after January 1, 2020 in order to qualify for the temporary FMAP increase.
States may also waive premiums for
CHIP enrollees, as well as premium lockout requirements for families
impacted by a disaster or public health emergency. To waive CHIP
premiums, states must submit a CHIP SPA. To waive premium lockout
requirements, states must submit an updated CS21 SPA.
Financing Flexibilities
Is there flexibility to
request/implement temporary rate increases or retainer payments in a
1915(i) SPA similar to those found in Appendix K for 1915(c) home and
community based services (HCBS) waivers?
States may increase Medicaid payment
rates to offset losses to providers during the COVID-19 pandemic, if
consistent with all applicable requirements, including section
1902(a)(30)(A) of the Act. FFP is not available under the Medicaid
state plan to pay providers directly for the time when care is not provided
to beneficiaries. However, on March 22, 2020, CMS released a template
that states may use to request a section 1115 demonstration to combat the
COVID-19 public health emergency, which allows states to request authority
to make retainer payments to certain habilitation and personal care
providers to maintain capacity during the emergency consistent with the
limitations set forth in Appendix K. The template may be downloaded
at this link: https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html.
States
may encounter in NF fee for service (FFS) rate components, including labor
costs related to overtime and other agency costs, supply costs for items
such as personal protective equipment, and childcare costs for NF
employees, among others?
States may submit SPAs to adjust or
supplement NF FFS rates to account for additional allowable costs of
operation associated with furnishing patient care. Such costs can
include increased labor costs, including overtime costs and additional
fringe benefit costs, as well as supply costs, including additional costs
associated with personal protective equipment. States can establish
time limits applicable to such a payment adjustment or supplement and also
establish criteria and conditions for facilities to qualify for the
adjustment or supplement. CMS will consider these SPAs on an
expedited basis, and additional flexibilities related to the SPA submission
and approval process may be available pursuant to emergency authorities
under section 1135 of the Act. States should contact their designated
CMS official for technical assistance with the SPA submission process.
How will CMS address Upper Payment
Limits (UPL) when states increase rates for NFs? Will the NF UPL
Demonstration Tools and Guidance change?
CMS UPL policy provides two general
approaches to demonstrating compliance with the UPL ceiling. States
can use a cost-based UPL approach to allow the UPL ceiling to fully
recognize the provider’s allowable costs of furnishing Medicaid services;
therefore, an increase in allowable facility costs can be accounted for in
the cost-based UPL ceiling. If a payment-based UPL approach is used,
states’ demonstrations can make adjustments to the payment-based ceiling to
the extent Medicare payment equivalents have increased.
During the public health emergency
period, can states receive federal funding to provide advanced payments to
providers as an interim payment and reconcile the advanced payments with
actual processed claims at a later point?
Under state plan authority, states
can submit a SPA to add an interim payment methodology that says, under
certain specified conditions, states will make periodic interim payments to
the providers. The interim payment methodology must describe how
states will compute interim payment amounts for providers (e.g., based on
the provider’s prior claims payment experience), and subsequently reconcile
the interim payments with final payments for which providers are eligible
based on billed claims. The interim payment methodology would not be
a prepayment prior to services being furnished, but rather would represent
interim payments for services furnished that are subject to final
reconciliation. CMS will consider such SPAs on an expedited basis and
additional flexibilities with respect to the SPA submission and approval
process may be available pursuant to emergency authorities under section
1135 of the Act. States should contact their designated reimbursement
contact for technical assistance with the SPA submission process.
Would CMS permit states to implement
Medicaid state plan payment methodologies that reimburse community programs
for days in which members are absent from
the program due to concerns about the spread of COVID-19 (e.g., Adult Day
Health)?
States may increase Medicaid payment rates
to offset losses to providers during the COVID-19 pandemic. However,
FFP is not available under the Medicaid state plan to pay providers
directly for the time when care is not provided to beneficiaries. On
March 22, 2020, CMS issued a new section 1115 demonstration opportunity
available to states under title XIX of the Act (Medicaid) (https://www.medicaid.gov/sites/default/files/Federal-Policy-Guidance/Downloads/smd20002-1115template.docx).
The demonstration opportunity allows states to request expenditure
authority to make retainer payments to certain habilitation and personal
care providers to maintain capacity during the emergency. For
example, adult day sites have closed in many states due to isolation
orders, and may go out of business and not be available to provide necessary
services and supports post-pandemic; the demonstration opportunity could
allow interested states to evaluate the effects on beneficiaries and the
Medicaid program of making retainer payments to mitigate a possible
long-term reduction in provider capacity and access to services. More
information about this demonstration opportunity is available at https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html.
CMS will work with states to review
all relevant statutory authorities, which may be available to support Medicaid
providers during the COVID-19 pandemic.
Would CMS permit states to implement payment methodologies
that reimburse self-directed workers for loss of hours due to concerns
about the spread of COVID-19?
States may increase Medicaid payments
rates to offset losses to providers during the COVID-19 pandemic, if
consistent with all applicable requirements, including section
1902(a)(30)(A) of the Act. However, FFP is not available to pay
providers directly for time when care is not provided to beneficiaries.
CMS will work with states on an expedited basis to review all
relevant statutory authorities to find potential pathways to support
Medicaid providers during the COVID-19 pandemic.
May states pay providers differently
than the approved state plan rate/methodology during the COVID-19 emergency
(i.e. higher rate and/or overtime wages)?
States would need state plan
authority to increase provider rates or change payment methodologies that
are specified in the state plan. States could implement these
policies through a SPA. We recommend that any SPA be implemented for a
defined period of time (e.g. through a state of emergency or ending on a
specific date). On March 22, 2020, CMS released a Disaster Relief SPA
template (https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/state-plan-flexibilities/index.html)
that can be used by states for this purpose.
Can states claim Medicaid
administrative match for COVID-19 related activities, such as surveillance activities
related to the spread of COVID-19?
Yes, to the extent states conduct
COVID-19-related activities for the administration of the Medicaid program
and can determine Medicaid costs through an allocation methodology that
meets all applicable cost allocation requirements, administrative match is
available. Amendments may be needed to the public assistance cost
allocation plan to allocate additional costs to the Medicaid program.
CMS will work with states on an expedited basis to assist in
determining cost allocation methodologies and updating cost allocation
plans.
If school is in session but being
conducted remotely, for the purposes of the Random Moment Time Study (RMTS)
used in allocating Medicaid administrative cost, please confirm that
eligible RMTS school staff may continue to respond to their sampled RMTS
moment indicating their activity for their sampled date and time (even if
they were working remotely).
Yes, even though the participant is
working remotely, he or she may respond to the sampled RMTS moment.
For those individuals sampled for the
RMTS who are not working, please confirm that the state or school district
can report the time as paid or unpaid time not working.
For those individuals who are
sampled, but are not working, the sample moment should be coded to paid
time not working if they are salaried, or unpaid time if they are
furloughed without pay or in some other unpaid status at the time of the
sample moment. The moments that are coded to paid time not working
should be reallocated across the other activity codes and a portion of the
costs recognized.
The current Medicaid Administrative
Claiming (MAC) Plan provides guidance for a situation when 85% percent RMTS
compliance isn’t reached, by allowing moments to be coded as non-Medicaid
until compliance is reached. However, the plan also requires
individual districts to reach 85 percent RMTS participation or potentially
incur penalties and/or non-participation in claiming. Would CMS be willing
to NOT impose individual district penalties while the school districts are
working remotely during the pandemic?
We recognize that RMTS overall staff
participation may be affected by the COVID-19 pandemic. During
the timeframe of the declared Public Health Emergency, CMS would not ask
states to impose any individual district penalties for districts that do
not reach 85 percent RMTS participation. States could modify the MAC
Plan to temporarily suspend this requirement during the public health
emergency.
Can states make new acuity-based
payments to providers who serve individuals with COVID-19 in community or
institutional settings?
States could submit a SPA or an
Appendix K for rates paid for services rendered in 1915(c) HCBS settings to
make acuity adjustments for payments for care to individuals in community
and institutional settings. For institutional settings, upper payment
limits would apply.
Can states allow facilities to
continue to receive full payment for a patient, even if there is a gap in
treatment services, due to a client being quarantined or shortages in
workforce for performing treatment activities (e.g., residential settings
where the facility must still provide for the basic needs, but may not be
able to meet the treatment requirements, such as 8 hours of treatment per
day)?
As long as a service has been
provided, CMS defers to states to determine whether an adjustment is
warranted. In the case of patient quarantined away from a facility,
states have the option to cover and pay for temporary absences under
Medicaid reserve bed authority discussed at 42 C.F.R. 447.40. If such
coverage is not currently provided for in the approved state plan, states
would need to submit a SPA. If a quarantined Medicaid patient
presents unique needs and resource demands, as indicated above, states
could use the state plan process to adjust payment rates and/or
methodologies to reflect the extra costs to provide services. On March
22, 2020, CMS released a Disaster Relief SPA template (https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/state-plan-flexibilities/index.html)
that can be used by states for this purpose.
Given the COVID-19 emergency
situation, are states still required to submit UPL demonstrations to CMS by
June 30, 2020, or is there flexibility around that deadline, as there is
for quarterly budget estimates (CMS-37) and expenditure reports (CMS-64)?
If states are unable to meet the
annual UPL submission requirement as discussed in State Medicaid Director
Letter 13-003 by the end of their state fiscal year, due to the COVID-19
emergency, please inform CMS and we will develop a state-specific
compliance plan. Currently, CMS does not take immediate financial
action against states based on a late UPL submissions.
Will CMS extend the deadline for
states’ Durable Medical Equipment (DME) UPL demonstration submissions as a
result of COVID-19?
If states are unable to meet the DME
UPL submission requirement due to the COVID-19 emergency, please inform CMS
and we will develop a state-specific compliance plan. Currently, CMS
does not take immediate financial action against states based on late UPL
submissions.
Will states continue to have secure
access to the Medicaid Budget & Expenditure System (MBES)/State
Children’s Health Insurance Program Budget & Expenditure System (CBES)
in the event that CMS buildings are closed?
Yes, CMS anticipates that states
would have continued secure access to MBES/CBES, as it is a web-based
application that is not dependent on whether CMS buildings are open.
Miscellaneous
What should states do if they need to
close Medicaid or CHIP state and local offices to applicants and
beneficiaries during a disaster or emergency?
CMS recognizes that the COVID-19
public health emergency may impact states’ normal operations, particularly
in light of staff shortages and the recommendations that individuals
socially distance themselves from others. As a result, we also acknowledge
that this may limit states’ ability to receive applications, reports of
changes in circumstances, and renewal forms or provide assistance
in-person.
While existing
statute and regulation do not permit an exception to accepting information from
applicants and beneficiaries through any of the required modalities(e.g., online, in
person, via mail, and by phone), CMS recognizes that access to a particular
modality may be temporarily limited due to an administrative or other
emergency beyond the agency’s control, including closure of public offices
due to COVID-19. If an emergency impacts a state’s ability to accept
information from applicants or beneficiaries in person or through another
modality, the state should make feasible adjustments to ensure that
individuals still have the opportunity to apply. For example, if state and
local offices are closed, a state could increase the capacity of other
available modalities (e.g., by expanding call center capacity or placing
additional out-stationed workers in specific locations), and ensure that
individuals are informed of these other resources. Additionally,
states should continue to ensure communication with applicants and
beneficiaries are accessible to individuals with disabilities and those who
are limited English proficient. CMS is available to assist states in
identifying practical solutions when access to a particular modality may be
limited due to the public health emergency.
Additionally, states may use
contractors to perform certain Medicaid agency administrative functions,
provided that the state exercises appropriate oversight consistent with
federal regulations at 42 C.F.R. § 431.10. For example, states
can use contractors to operate call centers, input data from paper
applications into an eligibility system or serve as application
assistors. For CHIP, states have broad flexibility to delegate
functions to contractors as long as they maintain oversight.
Managed Care Flexibilities
Could the COVID-19 pandemic have an
impact on state level managed care plan performance and quality measurement
efforts?
States use quality measurement in
many aspects of their managed care contracts to govern payment to the plans
as well as to providers. The COVID-19 pandemic has been disruptive to
clinical practices: for example, individuals have generally been advised
not to seek routine or preventive care unless medically necessary at this
time. Moreover, public health recommendations around social
distancing may lead to reluctance to conduct performance measurement and
external quality review (EQR) activities that require visiting health care
or health plan facilities. These recommendations have led some health
plan accrediting organizations, such as National
Committee for Quality Assurance (NCQA), to advise that states with
mandatory Healthcare Effectiveness Data and Information Set (HEDIS)
reporting requirements allow health plans to use 2019 HEDIS rates rather
than 2020 HEDIS rates for certain measures. All of these factors can
affect the actual performance of health plans on these quality measures, as
well as their ability to submit data to states on time. These factors
can also limit the accuracy of that information and the ability for states
to trend health plan performance rates over time.
Should states consider adjustments to
their managed care contract quality measurement requirements to account for
the changes in clinical practice resulting from the COVID-19 public health
emergency?
CMS recognizes that the current
COVID-19 pandemic is likely to affect clinical practices, and the timely
and accurate reporting of quality data such that states may need or want to
revise their contractual quality measurement requirements. Below are
some of the common ways states implement and incentivize quality
measurement in their managed care programs and issues to consider during
this public health emergency.
·
Withholds: Under 42 C.F.R. 438.6(b)(3),
states can implement a withhold, where a portion of a capitation rate is
withheld from a managed care plan (MCO, PIHP, or PAHP) and a portion of or
all of the withheld amount will be paid to the managed care plan for
meeting targets specified in the contract. Withhold arrangements are
frequently linked to quality performance measures or quality-based outcomes.
CMS strongly
advises states to work with their actuaries and their
quality measurement staff to determine if any changes are needed to the
data, assumptions and methodologies used to assess the ability to
accurately trend the quality measurement data and to determine the portion
of the withhold that is reasonably achievable. Should states believe
a change or elimination of a contractual withhold arrangement is warranted
due to the COVID-19 emergency, the state must submit a contract amendment
and, depending on the nature of the change, a rate certification amendment.
·
Incentives: Under 42 C.F.R. 438.6(b)(2),
states can implement an incentive arrangement, as long as total payment
under the contract is not in excess of 105 percent of the approved
capitation payments attributable to the enrollees or services covered by
the incentive arrangement. An incentive arrangement is an amount over and
above the capitation rates the managed care plan was paid for meeting
targets specified in the contract. Incentive payments are in addition
to the actuarially sound capitation rates, so while changes in clinical
protocols or access are likely to affect a plan’s ability to earn the
incentive payment, they do not affect the actuarial soundness of the
underlying rates. States may elect to reexamine the specified targets
for plans to earn the incentive payment; if a state chooses to do this, the
state must submit a contract amendment and depending on the nature of the
change, a rate certification amendment.
·
State-Directed Payments: Under 42 C.F.R. 438.6(c),
states are prohibited from directing how a managed care plan pays its
providers except for those payment methodologies that have been approved
and reviewed by CMS to be in compliance with 42 C.F.R. § 438.6(c).
For states that have approved directed payment proposals for this
rating period that condition payment to providers upon performance on
specific quality measures, states may want to reexamine these payment
arrangements to determine if changes are necessary or desired in light of
the COVID-19 emergency. If a state determines changes are necessary,
states will need to submit an amended directed payment preprint and,
depending on the nature of the change(s), contract and rate certification
amendments,.
·
General Contract Requirements and
Penalties: In
addition to the examples provided above, states may have several other
contract requirements related to plan performance or quality measures, such
as quality assessment and performance improvement (QAPI) requirements.
Some of these requirements may result in penalties imposed on the
plan(s) for failing to meet a certain performance level. It is within
state discretion to revise their contracts to remove or lessen such
penalties; however, states will need to submit contract amendments to
reflect any revisions. Depending on the nature of the change, a rate
certification amendment may be needed if such changes are expected to have
a material impact on the actuarially certified rates.
CMS is working to prioritize and
expedite reviews of COVID-19 related managed care actions. All managed care
actions (contract amendments, rate amendments, state-directed preprints)
needed to respond to COVID-19 should be submitted as soon as possible to CMCSManagedCareCOVID19@cms.hhs.gov.
Are there additional considerations
for External Quality Review-related (EQR-related) activities?
Some states contract with External
Quality Review Organizations (EQROs) to conduct the EQR-related activities,
while other states undertake these EQR-related activities themselves.
Given the extenuating circumstances presented by COVID-19, health plans
may find it challenging to submit accurate data to states and to do so on
time. Health plans may also request that external quality review
activities be limited if they would compromise the ability to maintain
social distancing, such as encounter data validation or performance
measurement validation that require onsite medical chart reviews. CMS
encourages states to work with EQROs and health plans to rely as much as
possible on quality data that can be submitted and validated
electronically, consistent with the EQR protocols per 42 C.F.R. §
438.350(e) and 438.352, to enable quality activities to continue while
minimizing the public health impacts of COVID-19. Where states determine
that some accommodations may be appropriate, CMS recommends that states work
with their quality measurement staff to determine the appropriate
accommodations and to submit a contract amendment.
Do states need to continue to submit
preprints for state-directed payments?
Yes, states are required to submit
preprints for state-directed payments. As noted above, any
state-directed payment preprints related to COVID-19 should be submitted to
CMCSManagedCareCOVID19@cms.hhs.gov.
CMS is committed to expediting and prioritizing such reviews.
Can states permit managed care
organizations (MCOs) to expedite decisions of beneficiary functional
eligibility for HCBS?
Federal regulations at 42 C.F.R. § 431.10(c)(2)
require states to make functional beneficiary eligibility determinations for
HCBS. As such, states can only delegate such determinations to
another governmental entity. However, states could permit MCOs to
conduct an assessment of eligibility and forward the assessment to states
for final determination.
What flexibilities does a section
1135 waiver provide related to appeals of adverse benefit determination
requirements in Medicaid managed care regulations at 42 C.F.R. Part 438?
Federal regulations at 42 C.F.R. Part
438 Subpart F establish appeals and grievance requirements for Medicaid
managed care. Section 1135 of the Act does not provide authority to
waive these requirements; however, CMS does have authority to modify
timeframes for required activities during an emergency period under section
1135(b)(5) of the Act. For example: states can request a section 1135
waiver to modify timelines for managed care plans to resolve an appeal to
no less than one day in order to permit earlier access to the state fair
hearing level. If states use this authority, all appeals filed would allow
managed care enrollees to quickly satisfy the exhaustion requirement in 42
C.F.R. § 438.408(f)(1) and proceed almost immediately to a state fair
hearing. In addition, states can modify timeframes under 42 C.F.R.
§ 438.408(f)(2) requiring managed care enrollees to exercise their
appeal rights within 120 days to allow more than 120 days to request a fair
hearing during the authorized period of the immediate section 1135 waiver.
In March 2020, CMS created a Medicaid & CHIP checklist for section 1135
waivers to assist states during public health emergencies, which is
available here: https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/section-1135-waiver-flexibilities/index.html.
Fair Hearing Flexibilities
What flexibilities are available for
Medicaid fair hearings?
In a disaster or public health
emergency, there are several state fair hearing flexibilities states may
utilize under current regulations. States may:
- Suspend adverse actions for individuals for whom the state
has completed a determination but either: (1) has not yet sent the
notice; or (2) who the state believes likely did not receive the
notice. This is consistent with 42 C.F.R. 431.211, which
requires the state to provide at least 10-days advance notice before
taking adverse action. See also Families First Coronavirus
Response Act – Increased FMAP FAQ B.9 regarding the provision of
continuous coverage during the emergency period as a condition for
receiving the increased FMAP under that Act.
- Delay scheduling fair hearings and issuing fair hearing
decisions under 42 C.F.R. 431.244(f)(4)(i)(B), which allows states to
delay taking final administrative action when there is an emergency
beyond the state’s control. States should prioritize completing
hearings that meet the standard for an expedited fair hearing under 42
C.F.R. § 431.224. States may offer to continue benefits to
individuals who are requesting a fair hearing if the request comes
later than the date of the action under 42 C.F.R. § 431.230.
- Hold fair hearings via video conferencing or telephone,
provided states adhere to other fair hearing requirements (42 C.F.R.
part 431, subpart E), including ensuring that the hearing system is
accessible to persons who are limited English proficient and persons
who have disabilities (see 42 C.F.R. § 431.205(e) and
435.905(b)).
- Reinstate services or eligibility if discontinued because
the beneficiary’s whereabouts were unknown due to displacement, after
the beneficiary’s whereabouts become known (if still eligible),
consistent with 42 C.F.R. 431.231(d).
States using any of these
flexibilities should seek concurrence from CMS. A formal request is
not necessary, and can simply be sought by email to the CMS state
lead. States should also maintain appropriate documentation in
accordance with the state’s record keeping practices. Delays in fair
hearings must also be documented in each case file.
Can states allow individuals
additional time to request a fair hearing?
Yes. States may request a
waiver under section 1135 authority to allow beneficiaries and applicants
to have more than 90 days to request a fair hearing for eligibility or
fee-for-service appeals. In March 2020, CMS created a Medicaid &
CHIP checklist for section 1135 waivers to assist states during public
health emergencies, which is available here: https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/section-1135-waiver-flexibilities/index.html.
The timeframe in 42 C.F.R. § 431.221(d) provides that states can
choose a reasonable timeframe for individuals to request a fair hearing not
to exceed 90 days for eligibility or fee-for-service appeals.
Do states have flexibility in fair hearing timelines in
response to a disaster or public health emergency?
Yes. States must take final
administrative action on a fair hearing request within the timelines
described at 42 C.F.R. § 431.244(f), except in unusual circumstances,
which may include an administrative or other emergency beyond the agency’s
control. States may extend the timelines for both Medicaid fair
hearings and CHIP reviews in such circumstances. For CHIP, states
should include such an extension in a CHIP SPA. For Medicaid, a SPA
is not needed. However, states should seek concurrence from CMS that
the hearings for which the state may exceed the time generally permitted
for taking final administrative action is reasonable. A formal
request is not necessary, and can simply be sought by email to the CMS
state lead.
Health Information Exchange Flexibilities
Can states request that FFP be provided through the process
described in 45 C.F.R. § 95.624 (emergency funding requests) to
connect non-pediatric Medicaid providers to Immunization Information
Systems?
Medicaid providers who do not treat children are much less
likely to have direct electronic health record (EHR) connections or EHR
integration with immunization information systems, and tracking the
administration of a vaccine in the adult population is more difficult due
to this lack of public health connectivity. These connections are
potentially eligible for enhanced funding under 42 CFR part 433, subpart C,
and states should begin planning for eventual vaccination efforts
accordingly. Please reach out to your Medicaid Enterprise Systems (MES) State
Officer for information on submitting an FFP request under 45 C.F.R.
§ 95.624.
What is the Patient Unified Lookup System for Emergencies
(PULSE) and how can states request that FFP be provided through the process
described in 45 C.F.R. § 95.624 (emergency funding requests) to deploy
PULSE resources to support COVID-19 response efforts?
The PULSE system provides first responders with
information critical to patient care through a nimble, easy to understand
system with access to patient health data (e.g., medications a patient is
taking) and is designed to be deployed immediately to assist in emergency
response. The first PULSE system was developed in California and has
been used for wildfire response within the state. A
COVID-19 iteration of PULSE (PULSE-COVID) supporting some
immediate use cases is now available. PULSE-COVID focuses on
collaboration with private sector partners and supports basic ad
hoc searches over the national health information exchange networks.
These searches could help medical response teams access critical
patient information via direct connections to the electronic health records
where their information is kept. The solution is hosted on a web
platform to enable quick and easy deployment to multiple states. Depending upon resources available for the
project, up to several states can be on-boarded to PULSE-COVID at once by
the public/private partnership overseeing the effort. There is a
range of capacity across the nation and immediate engagement would focus on
areas with the capacity to implement PULSE-COVID in the near term.
Please reach out to your Medicaid Enterprise Systems (MES) State
Officer for information on submitting an FFP request under 45 C.F.R. § 95.624.
How can states establish, implement, and enhance telehealth
technologies through the process described in 45 C.F.R. § 95.624
(emergency funding requests) as part of the COVID-19 response effort and in
support of their Medicaid provider and beneficiary populations?
CMS is available to provide technical assistance regarding
approaches to rapidly scale telehealth technologies. If states are
granted waivers under section 1135 for federal requirements related to
provider location or provider enrollment (https://www.cms.gov/files/document/covid19-emergency-declaration-health-care-providers-fact-sheet.pdf),
complementary technology investments may be appropriate. CMS advises
states to leverage existing infrastructure and technology. States
should discuss any patient-facing telehealth proposals with their Medicaid
Enterprise Systems (MES) State Officer. Please reach out to your MES
State Officer for information on submitting an FFP request under 45 C.F.R.
§ 95.624.
COVID-19 T-MSIS Coding Guidance
How should COVID-19 related service
codes be reported in the Transformed Medicaid Statistical Information
System (T-MSIS)?
States should ensure that systems are
coded to process the new codes and that providers have received updated
billing guidance. States should report COVID-19 related procedure
codes and diagnosis code information to T-MSIS as it is reported on the
original claims form. Please contact your CMS Systems Officer with
further questions. For information on COVID-19 testing HCPCS codes,
please see CMS’s
February 13, 2020 public health news alert. For information on
COVID-19 related diagnosis codes, please see the CDC’s
announcement regarding new diagnosis coding effective April 1, 2020.
How should telehealth-related
services be reported in T-MSIS?
States should ensure that providers
are educated on the correct submission of telehealth claims. States
should report COVID-19 telehealth services to T-MSIS as they are billed on
the claim form, identified through the procedure code and procedure code
modifier fields. Please contact your CMS State Systems Officer with
further questions. For general information on Medicaid telehealth,
see Medicaid
for Services Delivered Via Telehealth.
Will there be new federal reporting
requirements in T-MSIS for the new COVID-19 testing optional Medicaid
eligibility group?
To address the completeness and
accuracy of T-MSIS reporting for states adopting the new COVID-19 testing
optional Medicaid eligibility group, states should report the following two
data elements in the Eligible file to document a beneficiary’s enrollment
in Medicaid as defined by the FFCRA: ELIGIBILITY-GROUP (ELG087) and
RESTRICTED-BENEFITS-CODE (ELG097). An ELIGIBILITY-GROUP value of “76”
should be reported for an uninsured individual eligible for COVID-19
testing. A RESTRICTED-BENEFITS-CODE value of “F” should be reported
for an individual eligible for Medicaid but is only entitled to restricted
benefits for medical assistance for COVID-19 diagnostic products and any
visit described as a COVID–19 testing-related service for which payment may
be made under the state plan. Additional information and comprehensive
reporting guidance will be shared on the T-MSIS Coding Blog.
Will there be new federal reporting
requirements in T-MSIS for reporting claims
data for COVID-19 testing and testing-related visits for individuals
enrolled in Medicaid and CHIP?
There are three data elements in the
T-MSIS Claims files for state reporting of COVID-19 diagnostic products and
testing-related services.
(1) In the CLAIM-HEADER-RECORD, a
value of “17” should be reported in PROGRAM-TYPE for any COVID-19
diagnostic product or COVID–19 testing-related services as specified by the
FFCRA;
(2) In the CLAIM-LINE-RECORD, a value
of “136” should be reported in TYPE-OF-SERVICE, and a value of “107” should
be reported in BENEFIT-TYPE for any COVID-19 diagnostic product as specified
by the FFCRA;
(3) In the CLAIM-LINE-RECORD, a value
of “137” should be reported in TYPE-OF-SERVICE, and a value of “108” should
be reported in BENEFIT-TYPE for any COVID–19 testing-related services as
specified by the FFCRA.
Additional information and
comprehensive reporting guidance will be shared on the T-MSIS Coding Blog.
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