Medicaid & Medicare Prepare for the End of the Public Health Emergency

Earlier this year, President Biden declared his intention to end the federal public health emergency (PHE) resulting from COVID-19. Now set to end in May 2023, this announcement and a few key legislative actions are triggering a flurry of activity for the Medicaid and Medicare programs among states, health care providers, and payers.In March 2020, Congress passed the Families First Corona Virus Response Act and COVID-19 was declared to be a national public health emergency. In an effort to ensure that Medicaid enrollees would not lose their critically important health coverage during the pandemic, the law provided an additional 6.2 percent in federal Medicaid matching dollars to states on the condition that they not terminate coverage. Medicaid enrollment skyrocketed to unprecedented levels during this time, increasing by 29 percent by November 2022, according to the Kaiser Family Foundation. While the policy change achieved the goal of providing stable access to health care during the PHE, states are now facing a substantial challenge as they prepare to “unwind” and recommence the eligibility redetermination process.Starting this month, states may begin terminating Medicaid coverage for those members who are no longer eligible, or who failed to respond to a request for additional proof of ongoing eligibility. The Centers for Medicare & Medicaid Services (CMS), states, health systems, providers, and community organizations have long anticipated this complicated “unwinding” process and have been working in creative ways to assess impact, develop toolkits, adjust systems, and begin communicating what to expect.States have some flexibility about when they start processing redeterminations and how they prioritize populations, as long as they complete the process by June 2024. At a minimum, states must give enrollees 30 days to respond to a request for additional information before terminating coverage. This means that some states like Arizona, Arkansas, and Idaho are timing the first terminations to be effective in April, while others including Louisiana and Oregon are timing terminations to take effect in July and October, respectively.

Challenges, Including Equity Concerns with Medicaid Redeterminations

State Medicaid agencies have long known that restarting the redetermination processes and reach Medicaid’s highly mobile population would be an unprecedented challenge. CMS, the Federal Trade Commission, and Congress provided several flexibilities and requirements to facilitate the redetermination process and monitor the transition, but there is no getting around the fact that it will be complicated, even for those most prepared. The volume alone will exceed that of January 1, 2014 when states that elected the Medicaid expansion welcomed newly eligible populations.The process will also be inequitable, despite the best of intentions. Estimates suggest that as many as 6.8 million individuals who remain eligible for Medicaid will lose coverage. Individuals who moved and for whom states do not have accurate contact information, people with limited English proficiency, individuals with low literacy, and individuals with disabilities who do not qualify for ex parte renewals will face some of the greatest barriers and are likely to lose coverage for procedural reasons rather than actual eligibility eligible. The Office of the Assistant Secretary for Planning and Evaluation predicts that “children and young adults, as well as Latino and Black individuals, are predicted to be impacted disproportionately.”

How Managed Care Plans and Providers can Help

States are ramping up their Medicaid member communications activities this month, and there are several actions Medicaid MCOs and health care providers can take to help spread the word.  Managed care plans often have the most up-to-date contact information and interaction with their members and should encourage Medicaid members to update contact information, reply to notices, and may have the authority to help members enroll in alternative sources of coverage if no longer eligible for Medicaid. Additionally:

• MCOs can actively seek and share updated contact information for members with the state and conduct outreach to members pre- and post- disenrollment, as permissible by state law.

• Health care providers can share reminders when scheduling appointments, during visits, and even help with paperwork through in house navigation supports.

• Clinics that serve people who have limited English proficiency may be particularly helpful in helping people understand key action steps.

• Home visiting staff can help reach people who have limited mobility.

• Trusted community organizations including places of worship, community and recreation centers, food pantries, schools, and other frequently visited locations can provide key messaging and share information on social media.

Flexibilities Ending, Extending, and Adapting for Medicare Populations

While the Medicare program does not have an eligibility renewal requirement, a transition will also be occurring for those who serve Medicare beneficiaries as the PHE comes to an end. During the PHE, a wide variety of flexibilities were made available, including:

• The Emergency Medical Treatment and Labor Act (EMTALA) waiver allowing emergency departments to provide services in available adjacent buildings or tents;

• Offering a 20 percent add on payment for Medicare providers caring for patients diagnosed with COVID;

• Coverage of telehealth visits which had not previously been reimbursed under Medicare or Medicaid and waiving HIPAA requirements for telehealth being conducted in good faith;

• Providing COVID tests and vaccines at no cost for Medicare beneficiaries;

• Allowing medications to be prescribed via telehealth;

• Suspending the rule limiting Medicare beneficiaries to a 3-day stay in a Skilled Nursing Facility rule and authorizing patients to continue receiving SNF services without having the required 60-day ‘wellness period;’ and

• Authorized approvals of those that stood up Acute Care Hospital at Home programs to lessen the burden on hospital capacity.

• Relaxing the “refill too soon” standard to allow Medicare Part D prescriptions to be refilled at 90 days.

Depending on to what extent a hospital, clinic, health system, or MCO took advantage of these flexibilities, the end of the PHE brings opportunities and challenges to recalibrate. In some cases, this will involve going back to pre-pandemic requirements, like the EMTALA rules. However, for use of telehealth as a means of promoting access to care, it will be about identifying what worked well and what may need adjustment in order to optimize the potential going forward.For resources and more discussion on the end of the PHE and its implications for public programs, populations, and care delivery, check out the March episode of the Medicare Meet- Up here or wherever you get your podcasts.

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Author

Lauren Block [Vice President]