COVID-19 Health Policy Snapshots

12/9/2020

reports snapshots

NCSL has developed several policy snapshots—which include state policy options, state examples, federal action and key resources—on priority health topics related to the COVID-19 pandemic.

Testing and Coverage

COVID-19 Testing and Coverage | Download the PDF

Updated September 2020

COVID-19 testing is an effective tool to measure disease spread and inform appropriate public health interventions. Public health experts and federal guidelines rely on robust testing programs to identify COVID-19 hot spots, make informed decisions and support other key disease-control efforts, such as contact tracing.

States have determined their own testing plans and taken various actions to address barriers to testing; however, challenges with testing capacity and accessibility persist. According to Harvard’s Global Health Institute, most states are not conducting the amount of tests necessary to reduce the spread of the virus—which involves testing anyone showing symptoms and contacts of positive cases. Fewer states are regularly testing asymptomatic people in certain environments, such as nursing homes. Testing in high-risk settings can help prevent new outbreaks.

Additionally, confusion among payers, providers and the public over federal guidelines requiring private insurers to cover COVID-19 testing without cost-sharing to patients—coupled with millions of individuals recently losing their employer-sponsored coverage—have complicated efforts to ramp up testing.

Continued efforts to enhance COVID-19 testing and coverage, both broadly and for certain high-risk populations, can help states take the necessary steps to stop the spread of disease and safely reopen. This policy snapshot includes state policy options for supporting COVID-19 testing efforts and enhancing coverage for COVID-19 testing, as well as relevant state examples, federal action and additional resources.

State Policy Options

State legislators may consider the following options to expand testing capacity and accessibility:

  • Support state capacities and plans to carry out COVID-19 testing.
    • Allocate funding for testing.
    • Establish a task force or commission to support testing.
    • Prioritize certain vulnerable populations.
  • Enhance health insurance coverage for COVID-19 testing.
    • Ensure COVID-19 testing coverage for individuals with increased risk of exposure to COVID-19.
    • Extend testing coverage requirements to alternative health insurance plans.
    • Waive cost-sharing requirements for clinical visits for illnesses with similar symptoms to COVID-19, even if a COVID-19 test ultimately is not ordered or administered.
    • Provide testing coverage for uninsured individuals through Medicaid.
Policy Options
State Examples

Support state capacities and plans to carry out COVID-19 testing: Each state submitted a testing plan to the federal government with specific targets to mitigate the spread of the virus, protect vulnerable groups and account for adequate testing supplies and reagents. State strategies to scale up testing capacities include increasing laboratory processing; partnering with federal, academic or private organizations; establishing drive-through or mobile testing sites; or expanding access to multiple forms of tests, among other strategies. Policymakers are exploring ways to bolster these efforts and otherwise support states’ abilities to effectively carry out COVID-19 testing.

Allocate funding for testing. States are leveraging federal funds to pay for testing and disbursing funds to state health departments and local governments. Although states are facing budget shortfalls, many are providing additional funds to supplement federal support.

Illinois SB 264 appropriated $200 million from the Public Health Services Fund to the Department of Public Health for costs and administrative expenses associated with contact tracing and testing, including areas disproportionately affected by the pandemic. Minnesota SF 4334 approved $200 million from the state general fund to support costs related to COVID-19, including for the development of testing procedures and the establishment and operation of temporary testing sites.

Establish a task force or commission to support testing through legislative or executive action.

Massachusetts HB 4672 created a task force to make recommendations related to COVID-19, including increasing access to testing. Utah SB 3004 created the Public Health and Economic Emergency Commission to advise and make recommendations to the governor regarding the state’s response to the coronavirus emergency, including for a plan to promote widespread testing. In California, Governor Gavin Newsom created the California COVID-19 Testing Task Force, a public-private collaboration to boost testing capacity.

Prioritize certain vulnerable populations. As testing capacities remain limited, prioritizing certain groups can direct resources where they are most needed. Most states are prioritizing COVID-19 testing for essential workers and individuals in congregate living settings, particularly residents and staff in long-term care facilities.

Pennsylvania HB 2510 directed the Department of Human Services to establish guidelines for Regional Response Health Collaboratives to expand COVID-19 testing to include asymptomatic staff and residents in long-term care facilities. South Carolina HB 3411 required the statewide testing plan to emphasize testing in rural communities, and communities with a high prevalence of COVID-19 or with demographic characteristics consistent with risk factors for COVID-19.

Enhance health insurance coverage for COVID-19 testing: Out of concern that the costs of a COVID-19 test may deter individuals from getting tested, federal and state policymakers are aiming to limit out-of-pocket costs for patients. Federal law requires private health insurers to cover medically necessary COVID-19 testing without cost-sharing—including copayments, deductibles or coinsurance—to a health plan enrollee. For individuals covered through Medicaid, the Families First Coronavirus Response Act (Families First Act) requires states to waive cost-sharing requirements for COVID-19 testing and treatment in order to receive an increase in federal funding for their Medicaid programs. Some states have pursued additional requirements, beyond the federal standards, to address remaining coverage gaps and reduce patients’ out-of-pocket costs for COVID-19 testing.

Ensure COVID-19 testing coverage for individuals with increased risk of exposure to COVID-19, including essential workers who are unable to work remotely or remain socially distanced from others.

California issued an emergency regulation requiring state-regulated health plans to cover COVID-19 testing for essential workers free of cost-sharing or prior authorizations, regardless of whether the essential worker presents symptoms or has known exposure to the coronavirus. Essential workers include health care providers, home care workers, retail workers, emergency service personnel, employees in the education sector and several others. A West Virginia emergency order requires state-regulated health insurance plans to cover and waive cost-sharing requirements for COVID-19 testing for all residents and staff members of various long-term care facilities, such as nursing homes.

Extend testing coverage requirements to alternative health insurance plans, such as short-term limited duration plans (STLDs). STLDs typically offer coverage for less than a year but can be renewed for up to three years in many states. These plans are often exempt from various consumers protections established through the Affordable Care Act, such as requiring coverage for essential health benefits.

The Washington insurance commissioner released an emergency order requiring STLDs to cover COVID-19 testing without cost-sharing to patients. Idaho, North Dakota and Texas have requested, but not required, insurance carriers offering STLDs to waive cost-sharing for enrollees.

Waive cost-sharing requirements for clinical visits for illnesses with similar symptoms to COVID-19, even if a COVID-19 test ultimately is not ordered or administered.

Alaska and New Mexico have required state-regulated health plans to waive cost-sharing for tests and visits for illnesses with similar symptoms to COVID-19—such as pneumonia or influenza.

Provide testing coverage for uninsured individuals through Medicaid.

At least 20 states have extended Medicaid coverage for COVID-19 testing for uninsured individuals, as authorized by the Families First Act. For example, Minnesota HF 4556 authorizes uninsured individuals—regardless of age or income—to qualify for medical assistance coverage for testing without cost-sharing.

Federal Action

The Coronavirus Aid, Relief, and Economic Security (CARES) Act provided $140 billion for the Department of Health and Human Services (HHS), including $4.3 billion to the Centers for Disease Control and Prevention (CDC). Using these funds, CDC awarded $631 million to 64 jurisdictions across the country to expand their capacity for testing, contact tracing and containment. In May, HHS delivered an additional $11 billion for states through the Payment Protection Program and Health Care Enhancement Act to support COVID-19 testing, surveillance, contact tracing and related activities.

HHS has also continuously updated guidelines for implementing federal coverage requirements for COVID-19 testing. The guidelines identify the types of health plans that must meet federal standards (e.g., self-funded employer plans) and exempt private health insurers from covering COVID-19 testing for non-diagnostic purposes (e.g., back-to-work screen testing).

Additional Resources

Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.

Contact Tracing

Contact Tracing and COVID-19 | Download the PDF

Updated September 2020

Contact tracing is the process of identifying individuals who have an infectious disease and communicating with people they came in contact with to help prevent further spread. It is a core disease control activity that has been used by health departments for decades for several diseases, including tuberculosis, HIV and sexually transmitted infections. Contact tracing has been identified as a key component in the coronavirus pandemic for controlling outbreaks, managing COVID-19 cases and reopening safely. Although this public health tool is well established, the scale and speed required by the extent of COVID-19 cases among the U.S. population is unprecedented.

This policy snapshot includes state policy options to bolster contact tracing efforts and facilitate cooperation between tracers and contacts, as well as relevant state examples, federal action and additional resources.

State Policy Options

  • State legislators may consider the following policy options to support state capacities to carry out and facilitate participation in contact tracing during the COVID-19 crisis, and in preparation for future pandemics:
  • Ensure adequate resources and funding.
  • Recruit and coordinate a contact tracing workforce.
  • Maintain confidentiality protocols and privacy protections for data collected.
  • Increase awareness about contact tracing.

Policy Options

State Examples

Each state is managing its contact tracing plans differently, through a variety of approaches. Many state officials and health departments are leading in-house efforts, while others are partnering with organizations or contracting with a third party to secure staff, training and recruitment assistance. State legislatures are exploring ways to bolster these various efforts and support their state’s capacity to carry out contact tracing.

Ensure adequate resources and funding. State and local health agencies already have experience employing case-based strategies to reduce the spread of infectious disease. Scaling these efforts to the levels needed to respond to COVID-19 requires an expanded workforce and investigation capacity, and adequate systems and resources.

Hawaii SB 75 appropriates $14 million in funds received from the Payment Protection Program and Health Care Enhancement Act for COVID-19 outbreak control, contact tracing programs and personal protective equipment. Illinois SB 264 provides $200 million from the Public Health Services Fund to the Department of Public Health for costs and administrative expenses associated with contact tracing and testing in response to COVID-19, including in areas disproportionately affected by the pandemic. North Carolina SB 808 appropriates $125 million to the Department of Health and Human Services for testing, contact tracing, tracking and analyzing trends, and hiring temporary staff to augment contact tracing functions.

Recruit and coordinate a contact tracing workforce. The ability to build and maintain trust is an essential component of case investigation and contact tracing. To be done effectively, it requires a workforce with sensitive interpersonal skills and cultural competency appropriate to the local community. Certain factors, such as familiarity with various languages and cultural practices, may help the workforce efficiently support and communicate with patients and those with suspected cases.

District of Columbia Bill 759 establishes contact tracing hiring requirements, including a goal to hire at least 50% District residents and at least 25% graduates from a workforce development or adult education program funded or administered by the District of Columbia. New York SB 8362 requires the New York City Department of Health and Mental Hygiene and New York City Health and Hospitals to hire COVID-19 contact tracers under certain criteria. They must represent the cultural and linguistic diversity of the communities they serve to the greatest extent possible as a means to both distribute employment opportunity equitably and provide efficient epidemiological services to the community. South Carolina HB 3411 directs the Department of Health and Environmental Control to identify no fewer than 1,000 contact tracers—through its own staff and/or community partnerships—who are best suited to interact with populations disproportionately affected by COVID-19.

Maintain confidentiality protocols and privacy protections for data collected. Maintaining confidentiality during COVID-19 case investigations is important for legal reasons as well as public trust. Traditional case investigation and contact tracing programs include privacy protections for personal information. Explicitly outlining these standards, particularly around the use of digital technologies, may strengthen willingness to participate in contact tracing.

California AB 89 directs the Department of Finance to allocate federal funding to support state contact tracing, provided that funds are not used for applications that collect information related to an individual’s location and movement. Kansas HB 2016 enacts the COVID-19 contact tracing privacy act. It prohibits using any service or means that use cellphone data to identify or track, directly or indirectly, the movement of persons. Louisiana HCR 93 and HR 44 direct the governor to ensure that individual liberty and rights are protected as the state administers contact tracing.

Increase awareness about contact tracing. Actions to enhance transparency, increase public awareness, and address myths or doubts about the contact tracing process can help further build trust and cooperation.

District of Columbia Bill 776 authorizes the mayor to issue a grant or loan during a declared public health emergency to fund certain responses, including to increase awareness about and participation in disease investigation and contact tracing. South Carolina HB 5202 directs the Department of Health and Environmental Control to conduct a public awareness campaign to explain the use of contact tracing.

Federal Action

The Coronavirus Aid, Relief, and Economic Security (CARES) Act provided $140 billion for the Department of Health and Human Services (HHS), including $4.3 billion to the Centers for Disease Control and Prevention (CDC). Using these funds, CDC awarded $631 million to 64 jurisdictions across the country to expand their capacity for testing, contact tracing and containment. The U.S. Department of Labor authorized additional funding through the Dislocated Worker Grant, also awarded through the CARES Act, for states and territories to hire a contact tracing workforce. In May, HHS delivered an additional $11 billion through the Payment Protection Program and Health Care Enhancement Act to support COVID-19 testing, surveillance, contact tracing and related activities.

Additional Resources

Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.

Health Workforce

The Health Workforce and COVID-19 | Download the PDF

Updated August 2020

The COVID-19 pandemic has created an unprecedented demand for health care providers across the country. States, many of whom were already facing workforce deficits, are working to increase the number of health care providers to support the COVID-19 response and plan for future health workforce needs. Specific efforts include modifying telehealth policies, examining the scope of practice policies for certain health care providers and exploring regulatory changes.

This policy snapshot includes state policy options for legislators to maximize and expand the current health workforce to support the COVID-19 response, as well as relevant state examples, federal action and additional resources.

State Policy Options

State legislators may consider the following policy options to maximize and expand the health workforce to respond to the COVID-19 pandemic and prepare for future pandemics:

  • Use telehealth to enhance access to care for patients and providers.
    • Consider using telehealth, including phone consultations, as an allowable means for delivering health care services.
    • Explore allowing additional health care providers to provide telehealth.
    • Enable the provider-patient relationship to be established electronically.
  • Examine scope of practice requirements.
    • Evaluate current supervision requirements for certain non-physcician health care providers.
    • Assess current scope of practice requirements related to the practice and prescriptive authority of various health care providers.
  • Consider modifying licensure laws.
    • Allow health care providers who meet certain standards to practice under temporary emergency licenses.
    • Expedite the licensure process to ensure more health care providers can enter the workforce quickly.
    • Assess opportunities for allowing health care providers to practice across state lines, including reciprocity and/or interstate compacts.

Policy Options

State Examples

Use telehealth to enhance access to care for patients and providers: Enhancing and increasing access to health care services through telehealth is one strategy that every state has pursued during the COVID-19 pandemic. Telehealth allows for remote screening, triage and treatment of symptoms, potentially reducing disease transmission between health care providers and patients and between patients in the waiting area of health care facilities.

Consider using telehealth, including phone consultations, as an allowable means for delivering health care services.

Vermont HB 742 authorizes the Department of Financial Regulation to adopt emergency rules increasing access to health care services delivered via telehealth, audio-only telephone and brief telecommunication services.

Explore allowing additional health care providers to provide telehealth.

Ohio HB 679 (pending) expands existing telemedicine provisions to apply to additional health care providers, including psychologists, occupational therapists, physical therapists and professional clinical counselors.

Enable the provider-patient relationship to be established electronically, which gives patients easier access to providers.

Alaska HB 29 does not require that prior in-person contact occur between a health care provider and patient to establish a bona fide relationship.

Examine scope of practice requirements: State policymakers can examine the scope of practice for certain types of providers to determine if state laws allow them to practice to the full extent of their education and training. State scope of practice laws and regulations define the roles and responsibilities for health professionals’ licenses in each of these occupations.

Evaluate current supervision requirements for certain health care providers.

Minnesota SF 13 removes certain physician supervision and delegation requirements for physician assistants (PA) and provides for the annual review of a PA and physician practice agreement. For example, the bill removes direct supervision and allows for the development of a practice agreement.

Assess current scope of practice requirements related to the practice and prescriptive authority of various health care providers.

New York SB 8182 authorizes a licensed pharmacist to administer an approved vaccine for the coronavirus.

Consider modifying licensure laws: Temporarily modifying regulatory requirements and processes for licensure is one potential solution to ensure as many health care providers as possible are available to provide patient care during the COVID-19 pandemic. Many health professions are licensed in a way that can restrict the flow of workers across state lines. In response to COVID-19, states are opening up their licensing reciprocity to allow nurses, doctors, respiratory therapists and others to work across state lines, if they are licensed and in good standing in their home state.

Allow health care providers who meet certain standards to practice under temporary emergency licenses.

New Jersey SB 2333 authorizes the commissioner of health to issue provisional certification to emergency medical services personnel and paramedics, as well temporarily reactivate a paramedic’s inactive certification.

Expedite the licensure process to ensure more health care providers can enter the workforce quickly.

Alaska SB 241 allows the state’s division of professional licensing to expedite the process of issuing licenses to out-of-state applicants.

Assess opportunities for allowing health care providers to practice across state lines, including reciprocity and/or joining interstate compacts.

Missouri HB 2046 allows individuals licensed in certain trades who move to Missouri to be eligible for state license reciprocity if they have had their out-of-state license for at least a year and are in good standing.

Federal Action

In response to the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) released guidance temporarily broadening access to telehealth services in Medicare under the Coronavirus Preparedness and Response Supplemental Appropriations Act. The guidance removes rural and site limitations so telehealth services can be provided regardless of where the enrollee is located geographically and regardless of the type of site. CMS has also waived the requirement that a patient has a prior established relationship with a provider.

CMS is also issuing waivers for hospitals to use physician assistants and nurse practitioners to the fullest extent possible by waiving scope of practice requirements in Medicare following a state’s emergency preparedness or pandemic plan. These health care providers can now perform services autonomously, such as ordering tests and medications, that may have previously required a physician’s order. Finally, CMS is waiving Medicare and Medicaid billing requirements for providers to be licensed in every state where they provide services. The rule will allow certain licensed health care providers to practice across state lines, although these decisions are ultimately in the hands of the states.

Additional Resources

Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD3OA22893, National Organizations for State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. government.

Rural Health Care

Rural Health Care and COVID-19 | Download the PDF

Updated July 2020

Though early surges in COVID-19 cases have predominantly affected urban areas, the COVID-19 public health crisis may have a disproportionate effect on rural communities—potentially exacerbating existing rural health disparities. For example, rural Americans tend to be older and sicker compared to their urban counterparts—leaving them more susceptible to COVID-19. Additionally, 128 rural hospitals closed or ceased inpatient services between 2010 and June 30 of this year. Other health facilities, such as community health centers, are also feeling the financial pressure of the pandemic. During the COVID-19 crisis, however, access to care remains critical—and states can pursue various policy strategies to enhance the rural health delivery system and increase access to care in rural communities.

This policy snapshot includes more immediate and long-term state policy options for bolstering rural health care throughout and beyond the COVID-19 pandemic, as well as relevant state examples, federal action and additional resources.

State Policy Options

State legislators may consider the following policy options to mitigate the effects of COVID-19 on rural health care systems and prepare for future surges or pandemics, or both:

  • Support Rural Health Care Facilities.
    • Evaluate the financial effects of COVID-19 on rural hospitals and health care facilities.
    • Provide sustainable investment and emergency funding opportunities for rural health care facilities and providers.
    • Consider greater regulatory flexibility for rural health care facilities by evaluating certificate of need (CON) laws.
    • Pursue alternative payment models, which generally incentivize the value of health services over volume, to potentially provide a more predictable funding source for rural hospitals in the long term.
  • Increase Access to Health Care for Rural Patients.
    • Assess policies enhancing the availability of telehealth, including bolstering health insurance coverage for telehealth.
    • Strengthen private insurance coverage and affordability for rural Americans.

Policy Options

State Examples

Support Rural Health Care Facilities: Many rural hospitals and health facilities were already facing financial difficulties prior to the pandemic. Limits on elective surgeries and drops in routine care have only compounded these pressures. State legislators can support rural health care facilities through the following policy options.

Evaluate the financial effects of COVID-19 on rural hospitals and health care facilities.

Pennsylvania SB 841 requires the Pennsylvania Cost Containment Council to prepare a report on the various ways COVID-19 has affected hospitals and health facilities—such as evaluating the cost of staff training and recruitment and studying revenue losses due to limiting non-emergent services.

Provide sustainable investment and emergency funding opportunities for rural health care facilities and providers.

North Carolina HB 1043 provides $65 million in grant funding to establish the COVID-19 Rural Hospital Relief Fund. Funds will be allocated to designated critical access hospitals to offset the financial effects of COVID-19, including financial losses due to enhancing infection control protocols and triage, limiting non-emergent services and increasing the number of available beds for surge capacity scenarios.

Consider greater regulatory flexibility for rural health care facilities by evaluating CON laws.

At least 23 states have temporarily waived or provided an expedited review process for CON approval in response to COVID-19, according to NCSL research. Fourteen states have suspended requirements for multiple health care projects typically necessitating CON approval, while nine states have focused on specific CON requirements—often increasing a facility’s bed capacity.

Pursue alternative payment models to potentially provide a more predictable funding source for rural hospitals amid the pandemic—and once the pandemic abates.

Utah HB 2 directs the Utah Department of Health to work with rural hospitals on developing new reimbursement methodologies for inpatient billing in order to curb health care expenditures to the state.

Increase Access to Health Care for Rural Patients: Several barriers impede access to health care for rural Americans, including living far from the nearest hospital or lacking quality health coverage. Many states have quickly adopted changes to their telehealth policies to increase access to care and limit in-person contact during the pandemic. Additionally, while several states have expanded Medicaid eligibility to enhance access to health services, states can also pursue policy options aiming to improve private insurance affordability in the long term for rural residents.

Assess policies enhancing the availability of telehealth, such as ensuring payment parity and extending the types of covered services delivered via telehealth.

All 50 states have modified their telehealth policies in some capacity in response to COVID-19, with most state actions lasting for the duration of the pandemic. For example, Vermont HB 742 extends private insurance coverage to include teledentistry, requires coverage for store-and-forward modalities, and requires private health insurance plans to provide the same reimbursement for telehealth services as the insurer would for in-person services (i.e., payment parity).

Bolster private insurance coverage and affordability for rural Americans through policy options aiming to stabilize the individual insurance marketplace, such as reinsurance programs.

Twelve states have received federal approval and funding to operate a state-based reinsurance program through a Section 1332 waiver. Colorado SB 215 creates a special fee for certain health insurance carriers and hospitals to fund the state’s reinsurance program for an additional five years and provide insurance subsidies for certain individuals. The reinsurance program helped lower premiums for 2020 individual health plans, especially in rural and remote areas.

Federal Action

To ensure the U.S. health system has the capacity to respond to COVID-19, federal lawmakers appropriated funds through the Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Fund to support hospitals and other health facilities delivering vital services during the pandemic. The U.S. Department of Health and Human Services is in the process of distributing $175 billion in grants to hospitals and health care providers across the country, with $10 billion specifically targeted to rural providers. Hospitals and other providers can use federal dollars for treating COVID-19 patients and offsetting lost revenue due to the pandemic. Rural health clinics received just under $50,000 per clinic to support COVID-19 testing efforts.

Additionally, the Health Resources and Services Administration has distributed federal dollars supporting health care facilities responding to COVID-19. This includes nearly $165 million in CARES Act funding to 1,779 rural hospitals and 14 telehealth resource centers, $1.3 billion to health centers, and more than $21 million to look-alike health centers and health center controlled networks.

The CARES Act also authorized the Centers for Medicare and Medicaid Services to temporarily waive certain telehealth requirements for services delivered to Medicare enrollees. The guidance removes rural and site limitations so telehealth services can be delivered regardless of where the enrollee is located geographically.

Additional Resources

Medicaid

COVID-19 and Medicaid | Download the PDF

Updated July 2020

The COVID-19 pandemic has pushed the health system to its limits. Medicaid, as a major provider of health coverage, is in a unique position to help states respond to this global pandemic. Policymakers have many options to consider for using Medicaid programs and infrastructure to meet the increasing demand for health care services. Providing coverage to so many also makes Medicaid programs a major driver of state expenditures, and policymakers are grappling with how to leverage Medicaid to provide needed coverage through a pandemic with dwindling state revenues.

This policy snapshot includes state policy options for leveraging Medicaid programs in response to COVID-19, as well as relevant state examples, federal action and additional resources.

State Policy Options

The federal emergency declaration provides new options for flexibility at the state level to increase access to Medicaid services, such as section 1135 waivers and 1115 waivers that waive requirements during the emergency period. The Centers for Medicare & Medicaid Services (CMS) has issued guidance and templates for states to use to facilitate faster CMS approval of COVID-related requests for waivers and modifications to Medicaid programs. Usually 1115 waivers are required to be budget neutral, or not increase costs, to the federal government; however, the requirement will not be enforced for waivers for COVID-19.

State policymakers may also consider modifying Appendix K of their Home and Community-Based Services (HCBS) waivers to support older adults and people with disabilities. For more information, see the “Policy Snapshot: COVID-19 and Long-Term Services and Supports.”

These waiver authorities can be used, alone or in combination, to streamline Medicaid resources in response to COVID-19 and in preparation for future pandemics in the following general categories:

  • Adjusting Medicaid eligibility and enrollment.
  • Providing flexibilities to increase access to health care services.
  • Modifying enrollee cost-sharing requirements. 
  • Adding or adjusting existing benefits and services
  • Supporting health care service providers who participate in Medicaid.

Most of these new flexibilities are focused on increasing access to Medicaid, which can drive additional state expenditures. With the federal maintenance of effort requirements, described in the Federal Action section below, state policymakers have fairly limited options for controlling Medicaid spending during this emergency period. With the potential for significant revenue shortfalls, some policymakers may decide the additional federal funding does not provide enough relief to offset costs, and decline the additional funds. As of July 1, no state had yet chosen the option to decline.

The primary options available for reducing spending during this emergency period include reducing provider reimbursement rates and making administrative cuts to the Medicaid agency. Some states, like Colorado and Ohio, took these steps. Colorado, along with New York, has also incorporated budget reductions by delaying implementation or assuming the emergency period ends by January 2021. With uncertainty over when the emergency period will end, states may be faced with making deep cuts to other budget items.

Policy Options

State Examples

Eligibility and Enrollment. Policymakers may consider expanding eligibility criteria for Medicaid to cover additional individuals, simplifying eligibility determination processes and streamlining program enrollment.

Consider expanding Medicaid eligibility criteria to cover more people.

Thirty-seven states, Washington, D.C., and three territories have adopted the Medicaid expansion option offered under the Affordable Care Act, with some states using 1115 waivers to modify expansion to meet their specific needs. More than 20 states have expanded coverage for COVID-19 testing and treatment to uninsured individuals. Alaska and Washington allow coverage for certain out-of-state individuals.

Simplify eligibility requirements to gain and maintain coverage.

Eighteen states allow for self-attestation of eligibility criteria, particularly income. Self-attestation is not allowed for citizenship and immigration requirements.

Streamline enrollment using presumptive eligibility (PE) or expanding the entities allowed to determine presumptive eligibility.

Four states allow the Medicaid agency to determine presumptive eligibility. Illinois extended PE to the Medicaid ACA expansion population. (Illinois already provided PE for parents, former foster care youth and pregnant women.)

Access and Telehealth. Provide flexibilities to increase access, such as increasing use of telehealth, expanding allowable locations for services or temporarily expanding the criteria for qualified providers.

Expand coverage and/or access to telehealth services by allowing more services to be delivered through telehealth and/or expanding the allowable settings and technology.

New York enacted SB 8416 to allow telehealth services to be provided through video-only communication or audio-only in limited circumstances. Kentucky allows for case management and most HCBS services to be delivered via telehealth.

Expand the allowable provider settings for service delivery. For example, states may expand settings for home- and community-based services, which are typically required to be delivered in the home or a particular facility.

All 50 states, Washington, D.C., and three territories have used 1135 waivers to allow health services to be delivered in alternate settings. Georgia, for example, requested flexibility to use mobile testing sites, convention centers and hotels, and other temporary residential arrangements.

Cost Sharing. States may not charge premiums or copays related to coronavirus services or increase any existing cost-sharing requirements. However, policymakers may consider temporarily eliminating or modifying existing cost-sharing requirements.

Eliminate or waive deductibles, copayments, enrollment fees, premiums or other types of cost-sharing.

At least 20 states have eliminated or waived cost-sharing requirements for Medicaid services, with 17 states eliminating cost-sharing specifically for individuals with disabilities. For example, California and Maryland are eliminating cost-sharing requirements for certain low-income children.

Establish undue hardship waivers for cost-sharing requirements.

Missouri is using an undue hardship waiver to cover individuals eligible for a Medicaid buy-in for working individuals with disabilities.

Benefits and Services. Policymakers may consider adding new optional benefits or adjusting existing benefit limitations. Due to the maintenance of effort provisions from the Families First Act, states cannot cut optional benefits or reduce current benefit levels for the duration of the emergency period.

Consider optional benefits. States can choose to include optional benefits such as dental care and laboratory services.

Arkansas added a management and evaluation service for individuals with serious mental illness to provide check-ins while individuals may not be able to access their regular supports.

Adjust existing benefits by modifying current limits or waiving certain prior authorization requirements.

Kentucky and New Jersey have waived prior authorization requirements for all Medicaid services. Thirty-nine states allow at least some medications to be refilled early and/or increase the allowable quantity limits for medications.

Service Providers. Policymakers may consider many options related to providers, including relaxing qualifications, paying retainers to providers unable to offer services due to COVID-restrictions, or increasing reimbursement to providers dealing with increased demand.

Relax licensure and credential requirements, including accepting out-of-state provider credentials.

Fifty states and Washington, D.C., have used 1135 waivers to waive certain provider licensure requirements during COVID-19 and allow for out-of-state providers.

Increase reimbursement rates and/or use directed payments through managed care organizations (MCOs) to increase reimbursement to specific providers within an MCO’s network.

Alabama allows for reimbursement to dental providers to cover needed personal protective equipment. Arkansas is providing supplemental payments to direct care workers. Rhode Island temporarily increased overall reimbursement rates by 10%.

Pay retainers to service providers who were unable to provide services due to social distancing or other COVID-19-related restrictions.

Pennsylvania is providing 75% retention payments for certain HCBS services. North Carolina used an 1115 waiver to make retainer payments for personal care and habilitation services.

*Unless otherwise noted, the primary source for information in this table: Medicaid Emergency Authority Tracker, Kaiser Family Foundation.

Federal Action

The passage of the Families First Coronavirus Response Act (Families First Act), provides a temporary 6.2% increase to regular Federal Medical Assistance Percentage (FMAP) rates. In order to qualify for the increased federal matching funds, states must provide beneficiaries with COVID-19 testing and treatment with no cost-sharing requirements. In addition, the funding requires “maintenance of effort.” This means states may not make changes to Medicaid eligibility, including more restrictive requirements or premium increases, and they must maintain eligibility of all individuals currently enrolled and any who enroll during the emergency period. The Families First Act also provides states with an option to cover COVID-19 testing and test-related visits for uninsured individuals, with the federal government covering 100% of costs.

The Coronavirus Aid Relief and Economic Security Act (CARES) Act established a provider relief fund, which has made general distributions to Medicare and Medicaid providers as well as distributions targeted to specific provider types, like Medicaid dental providers

Additional Resources

Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UD3OA22893, National Organizations for State and Local Officials. This information or content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. government

Long-Term Services and Supports

Long-Term Services and Supports and COVID-19 | Download the PDF

Updated July 2020

Millions of Americans, including older adults and people with disabilities or chronic illnesses, require long-term services and supports (LTSS) to complete their daily routines. The coronavirus pandemic is a global crisis that may have greater implications for people who use LTSS as they are particularly susceptible to severe illness or death caused by COVID-19. As the primary payer of LTSS for millions of Americans, Medicaid is an important player in state COVID-19 responses for vulnerable populations.

This policy snapshot includes state policy options for legislators seeking to support access to LTSS and keep older adults and people with disabilities safe during public health emergencies such as COVID-19. It also provides relevant state examples, federal action and additional resources.

State Policy Options

State legislators may consider the following policy options to address the needs of older adults and people with disabilities during the COVID-19 crisis, and in preparation for future pandemics:

  • Long-Term Care Facilities
    • Strengthen data and reporting of COVID-19 cases.
    • Establish robust facilitywide COVID-19 testing.
    • Ensure adequate supply of personal protective equipment (PPE).
    • Address social isolation among facility residents.
  • Home and Community-Based Services (HCBS)
    • Increase flexibility in HCBS delivery via Appendix K of 1915(c) Medicaid waivers.

Federal Action

The federal Coronavirus Aid, Relief and Economic Security (CARES) Act provided $200 million to CMS to support additional infection control and conduct necessary survey and certification work related to COVID-19, including $80 million for states to increase inspections of nursing facilities. CMS will allocate the funding based on performance-based metrics.

In late July, the Trump administration announced it is allocating an additional $5 billion in COVID-19 relief funds to Medicare-certified long-term care facilities and state veteran nursing homes located in virus “hot spots.”

Policy Options

State Examples

Long-Term Care Facilities: Residents and staff in long-term care facilities account for an estimated one-third of COVID-19-related deaths across the U.S., and this estimate is thought to be higher in some states. Because of the age and underlying health conditions among nursing home residents, they are particularly susceptible to severe illness or death caused by the coronavirus. Additionally, the congregate nature of the facilities and the close physical contact between staff and residents create an environment in which there is risk for the virus to spread.

Strengthen data and reporting of COVID-19 cases. Timely and transparent data reporting can allow resources to be directed efficiently and active cases to be better isolated. In early May, the Centers for Medicare and Medicaid Services (CMS) issued a final rule requiring nursing facilities to report COVID-19 data at least once a week, and to make the data available to residents and their families. 

Massachusetts HB 4663 (pending) requires long-term care facilities to report daily the number of known COVID-19 positive cases and deaths among residents and staff at the facility.

Establish robust facilitywide COVID-19 testing. Testing of long-term care facility residents and staff is an important part of infection control to both keep the virus out of, and prevent spread within, long-term care facilities. A handful of states are creating plans for universal testing for both facility residents and staff.

West Virginia Executive Order 27-20 requires the West Virginia Department of Health and Human Resources and the West Virginia National Guard to “immediately” test every nursing home resident and staff member throughout the state.

Ensure adequate supply of PPE. The use of PPE, both by health care providers and long-term care facility residents, can help prevent the spread of COVID-19. 

New Jersey AB 4150 (pending) requires hospitals and long-term care facilities to maintain a 90-day supply of PPE during the coronavirus pandemic.

Address social isolation among facility residents. While limiting visitation and employing stricter social distancing measures inside facilities help protect residents, they can also lead to increased isolation and loneliness. States and local partners have explored new ways to engage with residents.

Kentucky's long-term care ombudsman is conducting well-check calls and purchasing technology equipment to help residents communicate with their families.

Home and Community-Based Services: More than half of Medicaid LTSS spending currently supports home and community-based rather than institutional care (e.g., long-term care facilities). Several factors contribute to this higher use of HCBS, including individual and family preferences and the relative cost-effectiveness of home and community-based care. Delivering essential health and other supportive services in homes and communities is critical to allowing vulnerable individuals to shelter in place and reduce risk of exposure to COVID-19.

Increase flexibility in HCBS delivery via Appendix K of 1915 (c) Medicaid waivers. Appendix K allows states to request an amendment to approved 1915 (c) HCBS waivers during emergency situations. These waivers aim to increase flexibility in HCBS delivery, ensuring continuity of care for HCBS waiver enrollees during the pandemic. They allow actions such as remote initial eligibility assessments, electronic service delivery, expanded settings for services and increased provider payments.

As of June 2020, CMS has approved Appendix K authority across all 50 states. According to Health Management Associates, these waivers include flexibilities such as:

  • Alaska is allowing providers to hire family caregivers as direct service workers for certain services, including in-home support.
  • Colorado is lowering the age limit from 18 to 16 for in-home direct care workers for certain services.
  • New Mexico is allowing nursing consultation and therapies to be delivered via telehealth.
  • Pennsylvania is increasing some service rates by up to 40% to account for excess overtime of direct support professionals, additional infection control supplies and service costs, and is providing 75% retention payments for certain services.
  • Rhode Island is allowing initial eligibility assessments to be conducted remotely.
  • Washington is expanding HCBS care settings to include hotels and churches.
Additional Resources
  • Preparing for COVID-19 in Nursing Homes provides guidance from the Centers for Disease Control and Prevention (CDC) for safeguarding residents.
  • CMS’ final rule requires nursing facilities to report COVID-19 data to the CDC weekly and to make the data available to residents and their families.

Please note that NCSL takes no position on state legislation or laws mentioned in linked material, nor does NCSL endorse any third-party publications; resources are cited for informational purposes only.

Medicaid and State Budgets

Medicaid and State Budgets | Download the PDF

Updated November 2020

When it comes to state budgets, Medicaid accounts for a significant portion of state expenditures and also the largest source of federal revenue for states. Medicaid is a “counter cyclical” program―when the economy contracts, Medicaid spending and enrollment grows. Prior to the pandemic, enrollment in Medicaid nationally has been declining, but is now on the rise due to the coronavirus pandemic and the resulting record unemployment. 

Similar to the Great Recession, states are now faced with leveraging their Medicaid programs to meet increased demand for coverage and access to health services, while facing potentially significant revenue shortfalls. With Medicaid accounting for such a large amount of state spending, states have historically targeted Medicaid for reductions in economic downturns.

But unlike the Great Recession, the coronavirus pandemic brings a unique set of financial challenges―how to meet increased demand for health services during a time when fewer beneficiaries can visit certain providers due to COVID-19 restrictions. To address these challenges, states may increase spending in some areas while looking to make reductions in others.

States are using a variety of strategies to reduce spending, such as cutting provider reimbursements and imposing service limits, as well as working to increase efficiency and program performance through alternative payment models or reducing fraud and waste. This policy snapshot includes state policy options for managing a fiscal crisis with increasing Medicaid budget pressures, including relevant state examples, federal actions and additional resources.

Federal Action

The passage of the Families First Coronavirus Response Act (Families First Act) provided a temporary 6.2% increase to regular Federal Medical Assistance Percentage (FMAP) rates. In order to qualify for the increased federal matching funds, states must provide beneficiaries with COVID-19 testing and treatment with no cost-sharing requirements. In addition, the funding requires a “maintenance of effort”―to qualify for the enhanced FMAP, states are required to maintain their current eligibility standards and may not make changes that restrict or reduce eligibility. States must also maintain current enrollment, including those who enroll during the emergency period.

State Policy Options

Drawing on lessons learned from the Great Recession and other economic downturns, the enhanced FMAP included in the Families First Act is meant to provide fiscal relief to states to help address Medicaid and general budget shortfalls and minimize the need for cuts to the Medicaid program. The American Recovery and Reinvestment Act (ARRA) of 2009 included a 6.2% across-the-board increase in FMAP, with bonus rates based on state unemployment rates. This enhanced FMAP allowed states to increase overall Medicaid spending to meet increased demand while also reducing state-level Medicaid expenditures. According to a 50-state survey conducted by the Kaiser Family Foundation, states used the enhanced federal funds from ARRA to:

  • Close or reduce Medicaid budget shortfalls.
  • Cover increased Medicaid enrollment.
  • Close or reduce state general fund shortfalls.
  • Avoid benefit cuts.
  • Avoid or reduced provider reimbursement rates.
  • Avoid or restore eligibility cuts.

At the present time, states are using the increased FMAP from the Families First Act in similar ways, though the current maintenance of effort requirements differ slightly from ARRA. The Families First Act requirement to maintain coverage for all beneficiaries throughout the emergency period may require increases in state spending. With this added pressure of continuous enrollment, states are considering policy options, legislatively and through executive action, to decrease spending in other areas as outlined in the table below.  

Policy Options

State Examples

Reduce provider reimbursements, including managed care organization contracts.

Nevada adopted a 6% across-the-board rate decrease.

Colorado adopted a 1% across-the-board rate reduction.

Michigan plans to cut $250 million from Medicaid largely by reducing rates paid to managed care organizations.

Florida’s governor vetoed planned increases to reimbursement for services provided to people with disabilities.

Eliminate or pause planned expansions or new initiatives.

Utah eliminated plans to extend 12 months of continuous Medicaid coverage to children.

Tennessee, Virginia and Washington planned to provide one-year postpartum coverage (an expansion from current 60-day coverage) but are no longer moving forward due to budget concerns.

Oklahoma withdrew plans to expand Medicaid; however, voters passed a ballot initiative to expand Medicaid in the state and the legislature is now tasked with finding funding.

Administrative cuts or freezes.

Maryland, New Mexico, Ohio, Virginia and Tennessee implemented hiring freezes.

Nevada, California, New Jersey and Washington have implemented furloughs for state employees.

Pharmacy cost containment strategies.

Thirty-three out of 43 states responding to an annual Medicaid survey indicated using new or expanding cost containment strategies in FY 2021, including:

  • Eleven states expanding their Preferred Drug List (PDL).
  • Eleven states using value-based payment arrangements to tie pharmacy reimbursement to client outcomes.
  • Seven states implementing policies to address Pharmacy Benefit Managers (PBMs).

Eliminate or reduce coverage or benefits.

Washington and Colorado proposed reductions to adult dental benefits.

New York proposed changes to eligibility criteria for personal care services.

Modify cost-sharing requirements, like premiums and copayments.

Colorado proposed increasing copayments for prescriptions and physician visits and adding new copays to dental and non-emergency medical transportation.

In addition to these policy options, there is a wide array of long-term options to reduce Medicaid spending, improve care outcomes and quality, and provide states with a return on their health investments. These strategies often involve upfront investments and may take years to see results, which can make them less desirable in the short term but potentially beneficial in the long term.  NCSL’s Policy Report, “10 State Strategies for Improving Medicaid,” details options states may consider, including adopting new payment models, decreasing fraud and waste, promoting healthy births, and improving overall performance and quality.

Additional Resources

Behavioral Health and COVID-19

Behavioral Health and COVID-19 | Download the PDF

Updated December 2020

Before the first reported cases of the coronavirus disease (COVID-19) in the United States, the country was already enveloped in several major behavioral health crises. Between 1999 and 2018, roughly 700,000 Americans died of a drug overdose. The majority of these deaths, around 450,000, were caused by opioid misuse. In the same time period, more than 700,000 Americans also died by suicide and rates of suicide deaths have increased by more than 30% in half of all states.

As state and local governments have responded to the COVID-19 pandemic, measures meant to mitigate the spread of the virus, like social distancing and stay-at-home orders, could be contributing to adverse mental and behavioral health experiences. Research has shown that economic disruptions, like a loss of a job or reduced income, have also increased the prevalence of adverse behavioral health experiences. In a study cited by the Centers for Disease Control and Prevention (CDC), 41% of adults reported at least one adverse behavioral health condition as a result of stressors brought on by the COVID-19 pandemic. The behavioral health effects of the pandemic also exacerbated health disparities with Black and Latino respondents, as well as women, who were significantly more likely to report mental health concerns. In survey data, Black and Latino respondents were also significantly more likely to report at least one economic hardship in the wake of the pandemic. 

This policy snapshot includes state policy options for legislators to improve access to behavioral health treatment, as well as relevant state examples, federal action and additional resources.

State Policy Options

State legislatures may consider the following policy options to improve access to behavioral health treatment and leverage federal financial resources to improve behavioral health outcomes during the COVID-19 pandemic:

  • Support telehealth services for behavioral health.
    • Expand telehealth services fr behavioral health.
    • Use teleprescribing services fr medication-assisted treatment.
  • Allocate CARES Act funds to support behavioral health.
  • Continue supporting access to naloxone.
    • Ensure funding fr naloxone distribution programs.

Policy Options

State Examples

Support telehealth services for behavioral health. COVID-19 is renewing states’ interest in telehealth services and increased flexibility from federal regulators has provided greater opportunities for states to expand their telehealth services.

Expand telehealth services for behavioral health. Changes in federal regulations have made it easier for behavioral health providers to offer services through telehealth. States can adopt these changes and other policy options, like expanding the kinds of providers that can participate in telehealth or requiring insurance providers and other payers to cover telehealth services, to improve access to telehealth services.

Louisiana’s HB 449 expands the types of health providers who can perform telepsychiatric evaluations to include psychiatric mental health nurses as long as certain requirements, including that such an examination takes place over videoconferencing technology, are met.

 

Maryland’s SB 402 allows for certain telehealth transactions to take place asynchronously, or over mediums that do not necessarily support “real time” transactions of information, such as self-reported medical conditions.

 

New Jersey’s AB 3843 required the state’s Department of Banking and Insurance to issue a bulletin mandating that telemedicine services should be treated the same as in-person visits and paid at the same rate as in-person services.

Use teleprescribing services for medication-assisted treatment (MAT). The Drug Enforcement Administration has updated its guidance for the duration of the public health emergency to allow remote prescribing of MAT for substance use disorders without an initial in-person office visit or without recurring in-person office visits to authorize refills.

Minnesota’s HB 105 extends certain waivers issued in the emergency declaration by the governor through June of 2021. These waivers include allowing initial evaluations and prescriptions to be completed through a telehealth visit and increasing the number of take-home doses of MAT medications a provider can prescribe.

 

Vermont’s HB 742 authorized certain health professionals to renew a patient’s existing buprenorphine prescription without requiring an office visit.

Allocate CARES Act funds to support behavioral health. Congress provided funding to states to address behavioral health priorities through the Coronavirus Aid, Relief and Economic Security (CARES) Act.

Use CARES Act funds to support state behavioral health priorities. States can direct federally appropriated funding to enhance behavioral health services and support other behavioral health priorities.

Minnesota’s House File 4490 appropriated funds from the CARES Act to enhance rural mental health services and outreach­­—including suicide prevention training, mental health awareness training for farm and rural adolescents, and creating mental health forums—in response to the COVID-19 crisis.

 

Colorado’s HB 1411 allocates CARES Act funding toward unanticipated expenses incurred as a result of COVID-19 for substance use disorder treatment providers, community mental health centers and other behavioral health care organizations in the state.

Continue supporting access to naloxone. Individuals experiencing an opioid use disorder may be at increased risk of overdose during the COVID-19 pandemic. Naloxone is a highly effective drug that reverses the effects of an opioid overdose. At present, all 50 states have enacted laws or created standing orders allowing individuals at risk of overdose to access naloxone without a prescription. Many states have required first responders to carry naloxone while on duty.

Ensure adequate funding for naloxone distribution programs. Several states have renewed or increased their financial commitment to these programs during the pandemic.

New Hampshire’s HB 1639 creates an opioid abatement trust fund, allowing the fund to reimburse the state and any political subdivision within the state for any portion of the cost of administering naloxone.

 

Pennsylvania’s HB 2387 provides $947,000 for the state’s naloxone reentry tracking program for high risk individuals. 

 

Virginia’s HB 29 appropriates $1,600,000 to purchase and distribute naloxone kits to treat emergency cases of opioid overdose or suspected opioid overdose.

 

 

Federal Action

Congress has taken steps to support federal agencies with behavioral health funding through a variety of financial support. The CARES Act included $425 million for the Substance Abuse and Mental Health Services Administration (SAMHSA) to address mental health and substance use disorders as a result of the COVID-19 pandemic. As part of that funding, certified community behavioral health clinics received $250 million to respond to the increased need for services related to depression, anxiety, substance misuse or other conditions.

SAMHSA also received $50 million for suicide prevention efforts and $100 million in flexible funding to address mental health and substance use disorders and provide resources to youth and people experiencing homelessness during this time.

On March 17, 2020, the Centers for Medicare & Medicaid Services (CMS) announced expanded waivers for telehealth, allowing providers to engage in telehealth on a wider array of platforms for the duration of the pandemic. Previously, telehealth providers had to meet strict security standards and engage with patients over a platform that allowed both audio and visual communication. Under an emergency declaration, the Department of Health and Human Services and CMS have indicated that they will waive HIPAA penalties for using non-HIPAA compliant videoconferencing software and expanded the kinds of platforms telehealth providers can use to provide care through Medicare and Medicaid.

Additional Resources

This paper is supported by The Commonwealth Fund, a national, private foundation based in New York City that supports independent research on health care issues and makes grants to improve health care practice and policy. The views presented here are those of the author and not necessarily those of The Commonwealth Fund, its directors, officers or staff.