National Health Law Program December 23, 2020 California Policy Needs During and After COVID: Eligibility, Enrollment, and Retention Alicia Emanuel & Skyler Rosellini I. Introduction The COVID-19 public health emergency (PHE) has fundamentally altered how California’s Medi-Cal program is administered. At the start of the pandemic, the state worked swiftly to seek waivers and other flexibilities of federal Medicaid requirements and to implement these COVID-19 flexibilities, including significant changes intended to streamline Medi-Cal eligibility and enrollment. In order to preserve Medi-Cal coverage for low-income Californians once the pandemic ends, California’s Medicaid agency, the Department of Health Care Services (DHCS), needs to plan now for its end. This issue brief highlights various policies the state put in place during the pandemic that should be continued after the pandemic, as well as other policies it needs to put in place now to mitigate harm to the Medi-Cal population once the pandemic is over. A. Overview of Federal Guidance and the Moratorium on Negative Actions The Families First Coronavirus Response Act (FFCRA) increased the federal government’s share of Medicaid costs (also known as the federal medical assistance percentage, or FMAP) by 6.2 percent to help states manage increased enrollment and state budget shortfalls due to the COVID-19 PHE.1 The increase lasts through the end of the calendar year quarter in which the PHE ends. As of the date of this publication, the Secretary of Health & Humans Services has extended the existing PHE through January 20, 2021 and therefore, the FMAP increase 1 Families First Coronavirus Response Act [hereinafter FFCRA], Pub. L. No. 116-127, 134 Stat. 178 § 6008(a) (2020), https://www.congress.gov/116/bills/hr6201/BILLS-116hr6201enr.pdf; Ctrs. for Medicare and Medicaid Servs., Families First Coronavirus Response Act - Increased FMAP FAQs (April 13, 2020), https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-faqs.pdf. California Policy Needs During COVID: Eligibility, Enrollment, and Retention 1 National Health Law Program December 23, 2020 remains in effect through at least March 31, 2021.2 In order to receive the increased FMAP, California must meet strong maintenance of effort (MOE) requirements.3 The state must retain eligibility standards that are no more restrictive than those in place as of January 1, 2020, and cannot charge higher premiums than were in place as of January 1, 2020. The state must also cover COVID-19 testing and treatment without cost-sharing. Additionally, under the continuous coverage provision, the state Medicaid agency cannot disenroll most beneficiaries who were enrolled as of March 18, 2020 through the end of the PHE. The continuous coverage requirement has played a critical role in preserving coverage for low- income Medicaid beneficiaries during the COVID-19 pandemic. CMS guidance interpreted the continuous coverage requirement as prohibiting most Medicaid negative actions during the PHE, including barring states from cutting benefits or increasing cost-sharing for Medicaid beneficiaries.4 To align with federal guidance, and Governor Newsom’s executive order N-29- 20, DHCS placed a moratorium on discontinuances and negative actions in the Medi-Cal program through the end of the PHE.5 DHCS also instructed counties to delay processing Medi-Cal annual redeterminations.6 Recently, CMS issued a new interim final rule (IFR) and proposed regulations that attempt to cut away at the continuous coverage requirement, by permitting states to eliminate optional benefits and increase co-payments and cost-sharing levels, among other harmful changes. As of the date of this publication, the impact of the IFR and the CMS proposed regulations on 2 HHS Office of the Assistant Sec’y for Preparedness and Response, U.S. Dept. Health & Human Servs., Renewal of Determination That A Public Health Emergency Exists (Oct. 2, 2020), https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx. 3 See FFCRA, supra note 1; See also Hannah Eichner, Nat’l Health Law Prgm., Top Ten List: Maintenance of Effort Requirement Compliance (June 2020), https://healthlaw.org/resource/top-ten-list- maintenance-of-effort-requirement-compliance-1-top-ten-list-maintenance-of-effort-requirement- compliance/. 4 Ctrs. for Medicare and Medicaid Servs., COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and Children’s Health Insurance Program (CHIP) Agencies 29 (June 30, 2020), https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf. 5 Cal. Dep’t Health Care Servs., MEDIL I 20-07: Access to Care During Public Health Crisis or Disaster for Medi-Cal (Mar. 16, 2020), https://www.dhcs.ca.gov/services/medi- cal/eligibility/letters/Documents/I20-07.pdf. [hereinafter “MEDIL 20-07”]; See also, Cal. Dep’t Health Care Servs., MEDIL I 20-14: Extension of Delaying Annual Redeterminations, Discontinuances, and Negative Actions Due to COVID-19 Public Health Emergency (May 29, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/I20-14.pdf. [hereinafter “MEDIL 20-14”]; See also, MEDIL I 20-26: Additional FAQs Due to the COVID-19 Public Health Emergency (Aug. 14, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/I20-26.pdf.; See also, MEDIL I 20-18: FAQs Due to the COVID-19 Public Health Emergency (June 2, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/I20-18.pdf. [hereinafter “MEDIL 20-18”] 6 Id. California Policy Needs During COVID: Eligibility, Enrollment, and Retention 2 National Health Law Program December 23, 2020 California’s Medi-Cal program is not yet known.7 The proposed regulations are undergoing a public comment period, which has not yet closed. II. Flexibilities California Put in Place During the COVID-19 Pandemic Here in California, DHCS implemented a variety of policies based on state and federal requirements and flexibilities, mandating the suspensions of negative actions for the duration of the PHE, halting discontinuances, and delaying processing of most annual renewals.8 The requirement to maintain continuous coverage applies to individuals who might otherwise lose coverage or have benefits negatively affected, such as individuals who age out of a Medi-Cal eligibility group, individuals who lose benefits (like SSI) that would affect their Medi-Cal eligibility, individuals who would move from Medi-Cal without a premium to one requiring a premium, and individuals who would move from a no share-of-cost (SOC) to Medi-Cal with a SOC.9 Additionally, DHCS instructed county eligibility staff to focus their limited resources on processing new applications and processing cases that would help beneficiaries gain access to care like inter-county transfers, a reported decrease in income, and adding a family member to the Medi-Cal case. These policy changes recognized that county workers had to quickly pivot operations because they started working from home and their work hours may have been impacted by caregiving duties or COVID-19. More importantly, these policy changes prioritize access to care for Medi-Cal applicants and beneficiaries living in the middle of the COVID-19 pandemic. Once the PHE ends, the Department will have to develop a system to methodically process backlogged Medi-Cal renewals so that beneficiaries do not inappropriately lose coverage, and to resume normal business operations. The following recommendations would help the state with planning for the unwinding of the current PHE-related flexibilities. A. Self-Attestation for Eligibility Requirements During the Public Health Emergency In line with longstanding DHCS guidance specific to public health emergencies and natural disasters, Medi-Cal applicants and beneficiaries can self-attest to eligibility information 7 Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, Interim Final Rule, 85 Fed. Reg. 71142 (Nov. 6, 2020), https://www.federalregister.gov/documents/2020/11/06/2020-24332/additional-policy-and-regulatory- revisions-in-response-to-the-covid-19-public-health-emergency. 8 Cal. Dep’t Health Care Servs., MEDIL I 20-15: Prioritizing Case Processing Activities Through the Duration of the COVID-19 Public Health Emergency (May 13, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/I20-15.pdf. [hereinafter “MEDIL 20-15”] 9 Cal. Dep’t Health Care Servs., MEDIL I 20-08: Follow-Up Guidance To MEDIL I 20-07 (April 10, 2020), https://www.dhcs.ca.gov/services/medi-cal/eligibility/letters/Documents/I20-08.pdf. [hereinafter “MEDIL 20-08”]; See also MEDIL 20-18, supra note 5. California Policy Needs During COVID: Eligibility, Enrollment, and Retention 3 National Health Law Program December 23, 2020 including income, California residency, and property, if the individual is unable to provide necessary verifications due to the public health crisis.10 In order to exercise this option, the county has the option of accepting a signed affidavit, under penalty of perjury, to verify the eligibility requirements in place of the requested verification documents.11 The only exception to this is citizenship or immigration status verification.12 This temporary policy allows individuals to complete an application without tracking down verifying documents such as pay stubs, tax documents, or bank statements. Additional guidance clarified that counties shall accept written affidavits telephonically signed. For individuals displaced