3 Forms of Medicaid Expansion that Can Increase COVID-19 Coverage

Medicaid expansion is key to securing national access to care for the new coronavirus and the federal government can and should support state programs for increasing COVID-19 coverage, according to the Kaiser Family Foundation.

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States can expand coronavirus care in three main ways:

• Broaden eligibility
• Ensure that eligible residents are enrolled or do enroll in Medicaid
• Submit additional waivers to CMS seeking greater flexibility in coverage and care access

The federal government can support Medicaid programs in their efforts against the virus by establishing constructive policies and taking appropriate, administrative action.

“As a source of coverage for one in five Americans, Medicaid can play a key role in connecting individuals to testing and treatment for COVID-19,” Artiga and Rudowitz wrote. “Through Medicaid, states can provide enrollees access to comprehensive benefits with limited out-of-pocket cost and receive federal funding with no pre-set limit to support coverage.”

Eligibility expansions can be enacted in a number of ways. 

The first, most direct and wide-reaching way is through Medicaid expansion. CMS recently encouraged states to take advantage of waivers and Medicaid expansion strategies in order to deal with this crisis.

Although researchers found that southern states that expanded their Medicaid programs saw more consistent patient outcomes and better healthcare coverage overall, many of the fourteen states that have yet to expand are located in the South. Now that every single southern state has been hit by COVID-19, however, some states may need to expand their Medicaid programs—whether they like it or not. 

Alabama, a southern state which has yet to expand Medicaid, now has two different motions in its state House which seek to expand Medicaid. One looks to expand coverage to new mothers and the other “extends the program to provide assistance to certain state residents in recognition, in part, of potential economic and health impacts of a COVID-19 outbreak.”

“Whereas, by not expanding Medicaid, this ensures that many Alabamians that may become infected will go undiagnosed and untreated; people for whom going to the doctor would result in financial calamity tend not to do so before their health circumstances become dire,” the second piece of legislation reads, “the members of the Democratic Party urge the Governor of the State of Alabama to expand Medicaid in this state under the Patient Protection and Affordable Care Act to enhance access to health care, promote revenue and economic activity, preserve and create jobs in this state, and protect the wellbeing of the citizens of Alabama.”

A second, alternative strategy to Medicaid expansion could include increasing CHIP coverage to encompass children who are higher above the federal poverty level, who are legal immigrants, or who are still in the womb.

On the flip-side, states can also reel in policies that have been used to restrict Medicaid eligibility—such as waivers that impose premiums or coverage lockouts.

States may also have a group of uninsured or underinsured individuals who are eligible for Medicaid but have not yet enrolled. Medicaid programs would do well to use marketing and to reach these individuals and help them enroll, Artiga and Rudowitz said.

Marketing for seniors who are dual eligible beneficiaries in aligned enrollment has proven to be a challenge. While aligned enrollment provides better care coordination for dual eligible beneficiaries, states have experienced issues with issuing information to these individuals and differentiating marketing for dual eligibles from marketing for the general Medicaid population, a recent GAO report found. 

Since risk is strongly tied to age, it would be critical to identify ways to reach this particular group of Medicaid beneficiaries.

Presumptive eligibility is not just for children and pregnant women, the researchers also emphasized. Presumptive eligibility allows schools, health centers, and select organizations to enroll patients on Medicaid coverage who seem eligible, while they are being processed. This is another way to increase coverage without full Medicaid expansion.

States can also suspend or postpone renewals and data checks to prevent Medicaid beneficiaries from losing coverage. 

Some states are already facing the potential reality of broad scale coverage losses in the midst of this crisis.

Louisiana, which is an expansion state as of July 2016, could see 24,000 people lose Medicaid coverage, according to local news outlets. Patients who no longer meet income requirements for Medicaid coverage will be kicked off of the Medicaid program starting mid-March.

The announcement comes only months after 46,000 Medicaid beneficiaries lost coverage in Louisiana, largely due to failure to fill out paperwork. In response, the state decided to send out pre-filled forms with their notices for Medicaid renewal. Nonetheless, the state stands to see another 24,000 lose their coverage simply due to a failure to turn in the required forms, Louisiana Budget Project Executive Director Jan Moller told local news outlets.

Moller said that the state should halt coverage suspensions in light of the impending COVID-19, but the state has shown no intention of doing so.

So far, Louisiana has seen 114 COVID-19 cases and two deaths.

Lastly, Section 1135 waivers and 1115 Medicaid demonstrations can give states more flexibility to better mitigate the coronavirus. For example, these waivers allow states to waive burdensome requirements for providers including the necessity for a state license to provide healthcare services, under the Section 1135 waiver, and cost-sharing or expand benefits, under the 1115 Medicaid demonstrations.

The federal government can play a role in expediting processes and eliciting a quick response to the crisis from state Medicaid programs.

The researchers recommended that CMS back off of the Medicaid Fiscal Accountability Rule (MFAR) and other policies that would limit funding to Medicaid state programs or create funding instability. Other potential policies that should be suspended, according to Artiga and Rudowitz, include the public charge rule and eligibility oversight.

In addition to ending or temporarily pausing these policies, the researchers recommended implementing policies that would increase federal financing, expand healthcare coverage for legal immigrants, and pass the Families First Coronavirus Response Act which is making its way through Congress.

“The strategies included here are not an exhaustive list of options, and, as with any such efforts, they could involve tradeoffs and may run counter to efforts by the Trump administration and some states to restrict eligibility, limit government spending, promote program integrity, and curb immigrant use of public programs,” the brief confessed.

However, despite ideological differences, potential tradeoffs and  policymakers are beginning to show more solidarity. Shortly before 1 a.m. on March 14, the Families First Coronavirus Response Act passed in a bipartisan vote of 363 to 40 and it has already received the president’s stamp of approval via Twitter.