States are working rapidly to ensure that individuals with complex medical conditions and their families have access to necessary home- and community-based services during the coronavirus (COVID-19) crisis. Under new federal rules, states can now temporarily amend programs serving Medicaid enrollees using long-term services and supports through waiver and state plan amendment applications.

The US Centers for Medicare & Medicaid Services (CMS) made it easier for states to temporarily modify their Medicaid policies and programs through state 1115 demonstration, 1915(c) Appendix K home- and community-based services, and Section 1135 public health emergency waivers. States can also streamline changes through Medicaid state plan amendments. These CMS checklists and templates are helpful tools for states preparing waiver applications.

For example, a Medicaid 1915(c) Appendix K waiver allows states to make temporary or emergency-specific changes to better address this public health crisis and protect its most vulnerable populations. Here are some of the options available to states under these waivers:

• Add services, such as necessary technology and home-delivered meals;
• Relax cost and coverage limits;
• Expand service settings, such as to hotels and shelters;
• Permit temporary payment for services rendered by family caregivers or legally responsible individuals;
• Modify provider qualifications to expand provider pools;
• Loosen reporting requirements;
• Expand or institute opportunities for individuals to self-direct their services; and
• Allow telephonic and videoconferencing to continue services remotely in home settings.

States Race to Respond

Pennsylvania, Washington State, and West Virginia were the first three states to receive federal approval for their Appendix K applications.

Pennsylvania received approval for six of its home- and community-based services waivers for adults with autism, people with disabilities, and older adults. For example, its Office for Long-Term Living has 90,000 adults enrolled in its Community Health Choices program. Pennsylvania’s Medicaid 1915(c) Community Health Choices’ Appendix K Waiver allowed the state to:

• Exceed service limitations on long-term or continuous nursing services as well as respite care beyond 29 consecutive days without prior approval;
• Expand habilitation service settings to private homes;
• Allow for remote habilitation therapy and counseling, assessments, and service coordinator meetings through phone or videoconferencing;
• Modify provider qualifications to allow more flexibility reassigning staff;
• Relax staffing ratios and number of individuals served due to staffing shortages; and
• Make retainer payments for personal assistance services for 15 days when the individual is hospitalized or absent from home due to COVID-19.

Washington State received approval for eight of its Medicaid 1915(c) waivers for its most at-risk populations needing home- and community-based services. Three of these waivers (Residential Supports, COPES, and New Freedom) are for older adults and adults with physical disabilities. The Appendix Ks for these three waivers allow the state to:

• Increase the amount and duration of waiver services as necessary on a case-by-case basis;
• Waive the timing of training, certification, and recertification for certain providers, including home care agencies, individual providers, and staff in adult family homes and assisted living facilities;
• Modify processes for case managers’ level of care evaluations and service planning to take place over phone or video, and allow for reassessments to be postponed for up to one year;
• Increase payment with an add-on rate to providers if necessary to ensure essential services, but the add-on rate may not exceed 25 percent of the provider’s current rate; and
• Make retainer payments to individual providers and residential providers for up to 30 days if the participant is hospitalized, absent from home, or the provider cannot enter the participant’s home due to COVID-19.

The proposed effective end date is Jan. 31, 2021, with individuals transitioning to pre-emergency status as circumstances allow.

West Virginia received approval for four of its Medicaid 1915(c) home and community-based services waivers for people with intellectual and developmental and physical disabilities, traumatic brain injuries, children with serious emotional disorders, and older adults. The Appendix K to the state’s aged and disabled waiver allows the state to:

• Continue at-home services but waive re-assessments and visits by outside staff;
• Exceed service limits for personal attendant services if the primary care provider becomes unavailable;
• Allow legal representative to be paid as personal attendants if the primary caregiver is not able;
• Allow provider agencies to provide online/telephonic training in lieu of in-person training;
• Suspend certification and reviews;
• Loosen regulations around service plans and allow for service planning meetings by phone; and
• Allow personal attendants to exceed time limits on essential errands.

These provisions are in effect until June 30, 2020, but the state can file for an extension if the pandemic is still active.

States now have added flexibility to loosen regulations to respond to COVID-19 for Medicaid beneficiaries with long-term needs and their families. While these measures are welcomed during this crisis, it will be important to evaluate their impact on individuals after the crisis ends:

• How will Medicaid deal with the cost overrides?
• How can states ensure access and quality of care under these new allowances?
• What were the impacts on Medicaid beneficiaries and their family caregivers?
• Should any of these expanded services – such as telehealth and assistive technology – be extended when the emergency situation ends?

As states race to respond to this pandemic, the National Academy for State Health Policy (NASHP) will continue to provide resources to states. NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living, is scheduled to publish a set of resources that detail Medicaid coverage of respite care, Medicaid payment to family caregivers and legally responsible adults, and Medicaid information/training/resources for family caregivers.