State Medicaid Programs Respond to Meet COVID-19 Challenges: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2020 and 2021

Eligibility and Enrollment

As part of the federal response to the COVID-19 pandemic, states meeting certain “maintenance of eligibility” (MOE) conditions can access enhanced federal Medicaid funding. The Families First Coronavirus Response Act,¹ amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act,² authorizes a 6.2 percentage point increase in the federal Medicaid match rate (“FMAP”)³ (retroactive to January 1, 2020) through the end of the quarter in which the public health emergency ends. To qualify for the enhanced funds, states must ensure continued coverage for current enrollees and are prohibited from increasing premiums or making eligibility standards, methodologies, or procedures more restrictive than those in effect on January 1, 2020, among other requirements.⁴

The MOE requirements⁵ contribute to enrollment increases⁶ by eliminating the usual enrollment churn that occurs when some individuals lose eligibility and are dis-enrolled from Medicaid each month. In the past, some eligibility churn occurred when otherwise eligible individuals lost coverage because they encountered barriers preventing them from timely documenting continued eligibility during the eligibility renewal process or when states conducted periodic data matches between renewals.⁷ Prior to the pandemic, these types of barriers were potentially depressing overall Medicaid enrollment levels.⁸

In addition to the MOE requirements, some states are utilizing Medicaid emergency authorities to take other actions to help people obtain and maintain coverage. These include actions to expand eligibility and make it easier to apply such as allowing for self-attestation of eligibility criteria; eliminating premiums; expanding the use of presumptive eligibility; and otherwise simplifying application processes.⁹ The beginning and ending dates of these policies vary by authority¹⁰ and many will expire with the end of the public health emergency (PHE) declaration (currently set for January 21, 2020).¹¹

Survey Findings

We asked states to report any non-emergency eligibility changes planned for FY 2021, including eligibility expansions, eligibility restrictions, and changes to enrollment processes. We also asked about changes to eligibility policies made in response to the COVID-19 pandemic and, specifically, whether states planned to adopt these changes on a more permanent basis. Finally, we asked states to report on outreach efforts to publicize COVID-19 related eligibility changes and/or the availability of Medicaid coverage following the economic downturn.

Non-Emergency Eligibility Changes

Seven states reported non-emergency plans to expand eligibility in FY 2021. As of October 2020, 39 states (including DC) have adopted the ACA Medicaid expansion (Figure 1).¹² Of these, 37 states to date have implemented expansion coverage to 138% FPL ($17,609 per year for an individual in 2020),¹³) including Idaho and Utah, which both implemented the expansion on January 1, 2020 (FY 2020), and Nebraska, which implemented on October 1, 2020 (FY 2021). Two additional states, Oklahoma and Missouri, will implement the expansion in FY 2022 as a result of successful Medicaid expansion ballot initiatives.

• Nebraska implemented the expansion on October 1, 2020 (FY 2021) pursuant to a ballot measure passed in November 2018. The state is currently seeking a Section 1115 waiver to implement its expansion with program elements that differ from what is allowed under federal law.
• Oklahoma voters approved a ballot measure on June 30, 2020 which adds Medicaid expansion to the state’s constitution and requires coverage to begin no later than July 1, 2021. The ballot measure language also prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population. The Oklahoma Health Care Authority intended to submit the necessary State Plan Amendments (SPAs) for expansion by September 30, 2020 with an effective date of July 1, 2021 (FY 2022).¹⁴
• Missouri voters similarly approved a ballot measure on August 4, 2020 which adds the expansion to the state’s constitution with coverage to begin July 1, 2021 (FY 2022). Like Oklahoma’s, Missouri’s approved ballot measure prohibits the imposition of any additional burdens or restrictions on eligibility or enrollment for the expansion population.

Six states reported plans to implement the following more narrow eligibility expansions in FY 2021. These other expansions include the following:

• Expanding coverage for parent/caretaker relatives and other low-income adults. One non-expansion state (South Carolina) has an approved Section 1115 waiver and plans to increase the income limit for parent/caretaker relative enrollees from 67% to 100% FPL and also to provide coverage with an enrollment cap for a new Targeted Adult group. Both expansions of eligibility are contingent on compliance with a work requirement. As a result of both the pandemic and litigation,¹⁵ no states are currently implementing approved work requirements.¹⁶
• Expanding coverage for postpartum women. Two states are expanding coverage for postpartum women beyond the 60 days provided under federal rules: Pending waiver approval, Georgia and New Jersey are extending to six months.¹⁷ (Additionally, Indiana reported plans to extend postpartum coverage to one year beginning in FY 2022.)
• Expanding coverage for certain older adults and people with disabilities. California is expanding income eligibility for the optional aged, blind, and disabled (ABD) population from 100% to 138% FPL and also creating a new ABD income disregard in the amount of the individual’s Medicare Part B premium (which is paid by Medicaid). The new disregard in California is expected to allow individuals to retain eligibility in the ABD pathway and reduce churn between the ABD and medically needy with share of costs pathways and administrative burden. New Hampshire reported plans to implement its “Medicaid for Employed Older Adults with Disabilities” program, which will expand Medicaid buy-in coverage for working people with disabilities to include those ages 65 and older with incomes up to 250% FPL. (New Hampshire already covers working people with disabilities ages 18 to 64 up to 250% FPL.) Louisiana is expanding HCBS waiver coverage for children with significant disabilities without regard to household income and assets for children who live at home but would otherwise qualify for institutional placement in a hospital, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities.

Only two states reported a planned eligibility restriction in FY 2021 after the expiration of the PHE. Missouri reported that scheduled premium increases would go forward after the PHE ended and Montana reported plans to implement a community engagement/work requirement and premium changes for expansion adults pending CMS approval of the state’s Section 1115 waiver renewal.

Although not counted as an eligibility expansion or a restriction for purposes of this survey, Texas reported that it would implement changes (including applying modified adjusted gross income (MAGI) financial eligibility methodologies to individuals eligible for family planning-only services) to its Healthy Texas Women (HTW) Section 1115 waiver program as required under the waiver’s January 2020 approval from CMS.¹⁸ The approved HTW waiver extended eligibility for family planning services to women age 18-44 up to 200% FPL not otherwise eligible for Medicaid and allowed Texas to waive non-emergency medical transportation (NEMT); retroactive eligibility; early and periodic screening, diagnostic, and treatment (EPSDT) coverage; and freedom of choice of provider for family planning services.

Two states reported non-emergency plans to simplify enrollment processes in FY 2021. Montana reported plans to implement an auto-renewal process for non-MAGI eligibility groups and Virginia reported plans to expand ex parte auto-renewals when individuals experience changes such as reaching the end of their postpartum coverage period or attaining an age requiring evaluation in other covered groups. While Virginia did not characterize this change as the extension of an emergency authority, the state did note that the proposed changes are intended to reduce caseworker caseloads when the PHE period ends.

Eligibility Changes in Response to COVID-19

Only five states¹⁹ reported plans to continue COVID-19 emergency changes related to eligibility and enrollment policies beyond the PHE period. One state (Vermont) noted that a variety of certain emergency flexibilities would likely extend beyond the PHE period due to the time required to re-implement prior policies. A few states reported specific plans for the continuation of policies to simplify/expedite enrollment processes:

• Massachusetts intends to continue allowing self-attestation of all eligibility criteria except for citizenship and immigration status.
• Washington is working to adopt self-attestation of income and resources for aged, blind, and disabled (ABD) populations. Washington also reported working to adopt hospital presumptive eligibility for ABD populations and post-enrollment verification of assets for ABD populations.
• Arizona indicated that it would continue allowing electronic signatures on eligibility documents for its long-term care program (institutional and HCBS).
• Virginia intends to continue allowing applicants and enrollees to verbally appoint/authorize assisters, advocates, and other individuals.

Another 12 states reported that the continuation of emergency eligibility and enrollment policies remained undetermined. Indiana and Louisiana reported that more time could be needed to re-implement their prior policies; Missouri indicated that it may continue to allow self-attestation of most eligibility factors for ABD and MAGI populations; and a few states (West Virginia, Kansas, and Missouri) reported potential plans to further extend renewal timelines.²⁰

At the time of survey completion, thirteen states had approved State Plan Amendments (SPAs) in place for the new Uninsured Coronavirus Testing group at the time of survey submission. This new optional eligibility pathway provides 100% federal matching funds for states to cover coronavirus testing and testing-related services for uninsured individuals through the end of the PHE. ²¹ In addition to this option, providers can alternatively obtain reimbursement for coronavirus testing and treatment provided to uninsured individuals from additional federal funds through the Health Resources and Services Administration.²² One state (California) reported covering a significant number of persons under its Uninsured Coronavirus Testing group as of June 30, 2020 (6,390). All other states reported more modest enrollments: Colorado, Louisiana, and Minnesota reported covering between 50 and 450 individuals and Maine reported covering approximately 850 individuals. Other states that had adopted the option (including Alabama, Iowa, Montana, Nevada, New Hampshire, South Carolina, and West Virginia) reported between zero and 50 persons covered and Washington has an approved SPA for this group but did not report the number of individuals covered. Since the time of survey submission, two additional responding states (Connecticut and North Carolina) have received SPA approvals for this group.²³

States reported a variety of outreach efforts to publicize COVID-19 related eligibility and enrollment changes, and ten states reported expanding enrollment assistance or member call center capacity during the PHE. Most states reported using their websites and social media platforms to provide COVID-19 related enrollment information. Many states also cited working with provider groups and advocacy organizations to disseminate information in addition to direct mailings to members and applicants and provider notices and alerts. A few states also commented on their managed care organizations’ (MCO) outreach efforts. Additionally, ten states (California, Florida, Indiana, Kentucky, Maryland, Missouri, Nebraska, South Carolina, Texas, and Virginia) reported expanding enrollment assistance or member call center capacity. Very few states reported experiencing application processing delays due to COVID-19 at the time of survey completion.

Oregon COVID-19 Medicaid Outreach

The Oregon Health Authority (OHA) created targeted messaging for potential applicants who may have recently lost a job, had a change in hours, or had a change in unemployment benefits and also created messaging about changes in eligibility for Medicaid, including changes in income, stimulus payments, and suspending case closure. The state has and continues to disseminate this messaging through customer service talking points, fact sheets and webpages, social media, e-bulletins, and plan and provider talking points, as well as through the statewide network of community assisters. The state also plans to send a direct mailing with this information to all Medicaid households. The OHA is also fostering a partnership with Oregon’s employment agency to ensure cross-promotion of vital information about eligibility and unemployment.