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States Re-think Contact Tracing and Case Investigation Strategies as COVID-19 Cases Rise
Contact tracing is an essential strategy for curbing the spread of COVID-19. When implemented quickly, isolation of people diagnosed with COVID-19 and identification and quarantine of close contacts can effectively interrupt disease transmission and reduce spread. Faced with rapidly climbing caseloads, testing delays, and increases in community spread, states and localities have had to prioritize high-risk cases, utilize technology in new ways, and implement creative strategies to conduct case investigations, trace contacts of infected individuals, and perform follow-up.
Contact tracing works best when quick follow-up is possible, sufficient testing resources are available, and when social isolation and quarantine are possible. Due to recent case spikes, contact tracers in some states are unable to call COVID-19-positive individuals fast enough. Additionally, with some regions reaching an accelerating state of community spread, it is more difficult to determine exactly where individuals were exposed to COVID-19. In North Dakota, these issues led to a major shift in contact tracing protocols. Since October, the state has asked infected individuals to notify their close contacts and direct them to resources on the Department of Health’s website.
Recently, other states have followed suit:
- The Maine Center for Disease Control and Prevention will make only one contact with an infected individual (instead of checking in with them periodically) to provide guidance. It will also enroll people in the program based on when their last contact with someone with COVID-19 was. That way, they will enroll people who have the highest number of days left in their 10-day quarantine period so Maine CDC can work with them as early as possible to limit exposure to others in the community. The state is also limiting its contact tracing to high-risk individuals, including those age 65 and older, health care workers, children, individuals of color, school workers, and congregate living facility residents.
- As of mid-November, Nebraska had a backlog of 2,600 people who had tested positive for COVID-19 but had not been contacted by a contact tracer. To address the backlog, the Department of Health and Human Services reduced the number of call attempts from five to two, reduced the number of interview questions, and asked individuals to call their own contacts to let them know they tested positive.
- New Hampshire began focusing on contact tracing for high-risk populations including health care workers, communities of color, and people living in group living spaces. The state is also asking health care providers to educate COVID-19-positive patients about isolation and quarantine procedures.
- Oregon has shifted tracking priorities as its case counts rise drastically to protect the state’s most vulnerable residents in long-term care facilities, jails, foster homes, etc. Contact tracers are still advised to perform the first two steps of tracing: interviewing new COVID-19 cases and finding their contacts and notifying them to get tested and quarantine, but they will no longer do ongoing monitoring of these groups.
- Pennsylvania is prioritizing case investigations of its most vulnerable residents, such as those in nursing homes, or cases that could lead to greater community spread.
- In Wisconsin and Wyoming, only individuals who have tested positive for COVID-19 will hear from contact tracers. Individuals are instructed to reach out to their own close contacts.
Since spring, states have shifted their approaches to contact tracing to reflect current needs. The examples above show that states are currently focused on maximizing contact tracing effectiveness by focusing on known or presumed positive cases and working to protect those at increased risk through a more targeted approach to contact tracing outreach.
Additionally, several of these states have been financing their contact tracing efforts with federal funds and there is some uncertainty about whether these funds will be renewed. With the year drawing to a close, there are competing demands for these resources as states prepare for vaccine distribution and education, and funding has likely played into decisions to cut back instead of hiring new contact tracers.
In response to state actions like the ones above, the US Centers for Disease Control and Prevention (CDC) released new guidance on Dec. 3, 2020, about how to prioritize contact tracing and case investigation in states and jurisdictions where cases are on the rise. The new directions were guided by several principles:
- Maximizing effectiveness;
- Protecting household contacts;
- Preventing outbreaks and clusters; and
- Protecting people at increased risk.
Source: Virginia has adopted these guidelines and will join the list of states that are using contact tracing prioritization as a way to address surging cases.
States can use other strategies in their contact tracing work to maximize value, including technology. As of Dec. 1, 17 states were using the Google and Apple exposure notification technology that alerts individuals when they have been in close contact with someone who has tested positive for COVID-19. There is an increasing focus on these phone applications working across state lines as the technology becomes more standardized. In other states, technology is being used to connect people with quarantine resources—a strategy that can make contact tracing more effective.
For example, in Connecticut, a statewide software system called ContaCT monitors test results and positive cases. The ContaCT platform will identify and refer people who need support at initiation and throughout self-isolation or self-quarantine. Case workers will support people in self-isolation or self-quarantine by connecting them with state, local, and regional resources as necessary, such as food and housing.
Other states are using a range of strategies to improve the efficiency or effectiveness of their contact tracing programs in the face of rising caseloads and hospitalization rates:
- The Ohio Department of Health is updating its systems to allow local health departments to enter information about an infected person’s contacts prior to their positive test to get a better idea of where the virus is likely to spread.
- Since August, Washington, DC contact tracing efforts have included home visits for high-risk individuals who did not complete contact tracing interviews or could not be reached by contact tracers.
- North Dakota, South Dakota, and Vermont have recently revived their partnerships with the National Guard to help with elements of contact tracing and case investigation.
- In New Mexico, businesses that have had a confirmed COVID-19 case or exposure among staff can avoid a 14 day Rapid Response Closure by signing a surveillance testing and contact tracing In the document the employers must agree to conduct testing among their staff and select a COVID-19 coordinator responsible for working with the NM Department of Health on contact tracing efforts in the workplace.
- South Dakota is incorporating texting and email into their initial outreach strategy, replacing phone calls in some cases. This approach can be more automated and will allow individuals to input their own information to a secure online portal even if they are unable or unwilling to answer the phone.
Contact tracing is just one piece of the puzzle when it comes to mitigating the spread of COVID-19. Increased public education about the importance of mask wearing and social distancing, as well as increased testing and resources for effective quarantine will also be critical for curbing the spread. As COVID-19 case numbers rise and fluctuate this winter, states are expected to continue to adjust their contact tracing and case investigation strategies to meet their needs and utilize available resources. The National Academy for State Health Policy, in partnership with Mathematica, will continue to track and analyze state efforts.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.
States Race to Create COVID-19 Vaccination Distribution Plans
As development of a COVID-19 vaccine continues, states are racing to develop vaccine distribution plans and are eager to ensure that the administrative challenges of testing and personal protective equipment distribution are not repeated. They must orchestrate vaccine storage and administration, data tracking, and capacity issues while questions about who will ultimately pay for the massive vaccine deployment, how it will be equitably distributed, and effective vaccine messaging require a uniform federal response for best results.
Last month, the US Centers for Disease Control and Prevention (CDC) released the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations. Its publication launched a 30-day deadline for states to create and submit their plans for vaccine-ordering, storage, and handling to the CDC by Oct. 16, 2020. The playbook, which acknowledged there are many unknowns and unanswered questions, will be continually updated by the CDC as guidance and best practices are refined. Recently, the National Academy for State Health Policy (NASHP) convened a cross-sector group of state officials to discuss their distribution strategies. The questions they raised are explored below.
How will the costs of preparation and planning for vaccine distribution be funded?
With CARES Act funding, the Department of Health and Human Services is distributing $200 million across 64 jurisdictions through the existing Vaccines for Children Program (VFC) for vaccine preparedness and planning. The funds are targeted to ensure jurisdictions can develop and update plans for their eventual vaccine distribution. These funds are used to ensure states’ Immunization Information Systems (IIS) are ready to accept all vaccine information, and that providers are enrolled and connected to the system to input their information, among other planning tasks. However, the CARES Act funding allocation uses a population-based formula and is not intended for other expenses related to vaccine administration, such as PPE, and must be spent by the end of 2020. With states already facing limited capacity given current budget constraints, these spending restrictions are expected to further strain state budgets, which could negatively impact their ability to distribute the vaccine to their most vulnerable populations.
State leaders also raised concerns about a variety of challenges they face in distributing the COVID-19 vaccine, such as a lack of clarity on federal funding for vaccine administration, refrigeration and storage, and availability of state funding.
According to the CDC playbook, the federal government will procure and distribute the vaccine and any associated supplies (including needles, syringes, and limited masks and face shields) at no cost to providers. Typically, insurance reimbursement to providers includes the cost of the vaccine itself and some of the associated administrative cost. The National Academies of Sciences, Engineering, and Medicine (NASEM) recommended in its framework for equitable vaccine allocation that vaccines be made available at no cost and that administration of the vaccine be adequately reimbursed. However, it is unclear how administrative expenses will be covered and by whom.
Other complications to state planning efforts include:
- What and how many vaccines will be rolled out, and over what time periods; and
- What refrigeration temperature requirements will be.
For example, given the storage and temperature requirements of one COVID-19 vaccine currently in clinical trial, states are concerned about additional costs of storing, freezing, delivering, and administering vaccines. CDC, meanwhile, has instructed states not to invest in ulta-cold freezers yet.
Vaccine administration can also be prohibitively expensive for facilities. Because there are still so many unknowns about which vaccines will be available and how they will be transported, details about who will ultimately finance these costs are still being finalized. State officials expressed concern that as they face budget crises and limited federal information and regulations, they are being set up to fail.
Who will be the first to be vaccinated?
The CDC recommends that states establish COVID-19 vaccination program implementation committees with representatives from every sector and from communities. The NASEM framework highlights the need for equal regard, maximization of benefits, evidence-based actions, and transparency in decision-making. NASEM and the Advisory Committee on Immunization Practices (ACIP) have been discussing how to prioritize the distribution of the COVID-19 vaccine to critical populations, but delayed making a final decision until a vaccine has been approved by the US Food and Drug Administration for clinical use.
Source: CDC COVID-19 vaccine implementation presentation, July 29, 2020.
The CDC playbook highlights a phased approach to distributing the vaccine and delineates three phases of distribution. However, during Phase 1, which has a limited supply of COVID-19 vaccine doses available, states are encouraged, but not required, to focus their initial efforts on reaching critical populations, including:
- Health care personnel who are likely to be exposed while treating people with COVID-19;
- Those at increased risk for severe illness, including those with underlying medical conditions and people age 65 years and older; and
- Other essential workers.
These phases align closely but differ slightly from NASEM’s equitable distribution framework for Phase 1.
Most state officials noted they intend to follow this guidance for prioritizing an equitable vaccine distribution. But, some states also noted concerns regarding using their immunization systems to identify and distribute the vaccine to these populations, especially to those who live in large, sparse, rural, and frontier areas with smaller public health administrative capacity. Others raised concerns about whether individual providers will be able and willing to administer the vaccine, and if they can do so in a way that follows the equitable allocation framework. Their concerns are tied to cost and reimbursement levels, as well as physical capacity to store and refrigerate the vaccines. Additional federal guidance and funds could alleviate these issues.
Who will pay for the vaccine and associated costs?
The NASEM framework recommends that the COVID-19 vaccine be provided and administered with no out-of-pocket costs. Paul Mango, HHS deputy chief of staff for policy, said the agency’s goal is for the COVID-19 vaccine to be free for all Americans. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, similarly noted, “… The vaccine itself has already been bought by the federal government… A person who gets a vaccine will not pay for the vaccine.” However, Fauci did note that patients could be charged for costs related to the vaccine’s administration. Confusion remains about how these decisions will be made and it remains unclear how administrative expenses will be covered and by whom. For example, in the VFC Program, a provider who administers a qualified pediatric vaccine to an eligible child may not impose a charge for the cost of the vaccine, but can charge a fee for its administration as long as the fee does not exceed the costs of the administration.
ACIP has not yet issued a recommendation on state coverage of a COVID-19 vaccine, but Section 2713 of the Public Health Service Act requires mandatory coverage of all ACIP- recommended vaccines for state Medicaid expansion programs and most commercial health plans (state-based exchanges). ACIP-recommended vaccines are considered preventive and therefore are not subject to cost-sharing by patients. In March, Congress added a COVID-19 vaccine to the list of vaccines commercial health plans are required to cover. Usually insurers have up to a year after a vaccine is recommended by ACIP to implement coverage, but the CARES Act drastically speeds up this timeline by requiring plans to cover a COVID-19 vaccine within 15 days of its approval. The Coronavirus Preparedness and Response Supplemental Act specified that a vaccine should be priced “fairly and reasonably.” And, US officials noted over the summer that they expect insurance companies will not charge copays for COVID-19 vaccinations.
The cost of the vaccine for Medicaid enrollees is expected to vary by state. While Medicaid expansion states require complete coverage of ACIP-recommended vaccines without cost sharing, vaccine coverage is optional in non-Medicaid expansion states and remains up to the state’s discretion. However, through the Families First Coronavirus Response Act, all states are eligible for a temporary (through the end of the public health emergency) 6.2 percent increase to their Federal Medical Assistance Percentage (FMAP). One condition for states to receive this money is that the state plans must cover, without cost sharing, COVID-19 vaccinations.
For Medicare enrollees, vaccines are typically covered under Medicare Part D, which allows for cost sharing. The Centers for Medicare & Medicaid Services (CMS) can opt to cover the COVID-19 vaccine under Medicare Part B (which already covers the influenza vaccine and the pneumococcal pneumonia vaccine), a move that would prohibit cost sharing. As of mid-September, officials were still working with Medicare to figure out the cost to beneficiaries, but noted that the cost would likely not exceed $3.50 out of pocket per individual.
How will states monitor vaccine distribution?
The CDC is developing a Vaccine Administration Management System (VAMS) to manage vaccine administration and provide real-time data from mass-vaccination clinics to federal agencies and state public health departments. The system, funded by an almost $16 million sole-source contract, is designed to share data with existing Immunization Information Systems or immunization registries used by states and territories to record vaccine administration, order vaccinations, and send out vaccination reminders to patients. As of Oct. 7, 2020, however, VAMS has not yet announced plans, leaving state leaders confused about how to plan for vaccine tracking. Concerns have been raised that VAMS might bypass state systems, leaving states unsure whether they will need to use the new system or be able to enhance their existing immunization registry systems in time.
Immunization registries – either VAMS, IIS or a combination of both – will be needed to record vaccination information, identify individuals in need of a first or second dose of a vaccine, remind individuals to get vaccinated, and track follow-up. One critical concern is whether immunization registries have the capacity to ensure that people receive a second dose of the vaccine within an acceptable timeframe and that they receive the same type of vaccine for both doses.
Historical underinvestment in IIS has resulted in wide variation across states’ IIS policies, size, and scope. They have different patient consent policies, reporting mandates, and data-sharing policies. In some states, provider participation in the IIS is mandated by law, and in other states participation is voluntary. As a result, only 55 percent of immunization programs have 95 percent or more of individuals in their jurisdictions registered in their IIS. There is also inconsistent communication between systems. Many electronic health record (EHR) systems are not connected to immunization registries, leaving individuals who receive vaccines at different locations with incomplete immunization records. Although some states receive matching funds available through the Health Information Technology for Economic and Clinical Health Act (HITECH) to enhance interoperability of electronic data exchange between EHR and immunization registries, many rely on the CDC, private foundations, and health care providers and insurers to fund their systems.
Because multiple COVID-19 vaccine doses are forecast to be required, strong data-sharing capabilities between registries also is critical. State IIS need to be able to talk to other health records systems and other states’ immunization registries in order to ensure that individuals receive the correct second dose at a different facility, and even in a different state if necessary. However, in 2018, only 10 percent of immunization registries had conducted at least one query of an IIS in another jurisdiction. While the need for better systems to distribute and monitor the COVID-19 vaccine is clear, because VAMS has not yet released plans, states are left to figure out whether and how to:
- Upgrade existing systems, which requires time and resources;
- Rely on a new system that will be unfamiliar to providers and clinics; or
- Use a combination of both.
How are states promoting public trust in the vaccine?
Vaccine hesitancy will also be a critical issue. According to a recent Pew Study, the number of adults who say they will get a COVID-19 vaccine has fallen from 72 percent in May 2020 to 51 percent in September. Another study found that 35 percent of Americans would not get a vaccine, even if it were free. Mistrust of health care is especially prevalent among Black communities, who are skeptical of the medical system because of current and past discrimination against people of color. This distrust continues as Black Americans are hit hardest by COVID-19, making it even more critical that the government finds ways to boost confidence in COVID-19 vaccine safety.
The need for standardized public health messaging during this pandemic is also clear. In fact, state officials noted that currently, clear and consistent vaccination messaging is one of the biggest issues that states need the federal government to address. Typically, states use a variety of mechanisms for disseminating vaccine information, such as partnering with community organizations, hospitals, and other state agencies to disseminate information to their constituents, sending out clinician letters to providers and pharmacists, and using IIS to send vaccine reminders to patients. These strategies will continue to be important when states market the importance of getting the COVID-19 vaccination.
At the same time that state officials are concerned about gaining and developing public trust in the vaccine, they also need to manage expectations about vaccine availability and efficacy. As noted, the CDC playbook asks jurisdictions to plan for three phases of distribution:
- During Phase 1, critical populations such as essential workers and high-risk individuals are prioritized;
- In Phase 2, limited doses will be available to the public; and
- In Phase 3, there will be sufficient vaccine supply for the entire population.
Public health officials are tasked with instilling confidence in the COVID-19 vaccine and conveying the importance of getting vaccinated to the general public, while simultaneously making it clear that most individuals will not be able to get vaccinated until Phase 2 or 3, which is anticipated to start in fall of 2021. Until that point, and even after, individuals may still need to take other effective measures to present the spread of COVID-19, including social distancing and wearing masks.
State leaders are already concerned about this shift in messaging between phases, and worried about overpromising outcomes without increasing anxiety about the vaccine’s efficacy. In order to help manage expectations about when the vaccine may be available to the public while also combatting vaccine hesitancy, consistent messaging across federal and state agencies is urgently needed.
What partnerships are needed at the state and local levels to ensure seamless vaccine distribution?
As highlighted in the CDC playbook, the pandemic vaccination response requires collaboration among many public and private stakeholders to create and implement plans. State officials at the NASHP meeting noted the complexity involved in rapidly developing plans across agencies and across the public and private sectors.
Officials also raised the issue of involving pharmacists as vaccinators, and onboarding them into IIS. While all 50 states do currently allow pharmacists to vaccinate adults, and recent federal action gives state-licensed pharmacists authority to provide the COVID-19 vaccine to persons age 3 and older, only some states have pharmacists enrolled in Medicaid and the VFC program, with some pharmacists citing difficulty in being reimbursed during previous public health emergencies. Some state officials raised concerns that using pharmacies as immunization access points for COVID-19 could disrupt care in medical homes, particularly for children (although children will not be included in the first round of COVID-19 vaccines.) While the playbook highlights the need for increased access to the vaccine to ensure equitable distribution, states are considering how to balance widespread access to the vaccine with maintaining the importance of medical relationships within existing networks.
What federal leadership is needed?
Despite guidance provided by the CDC, there is currently no unified federal plan for distribution of a COVID-19 vaccine, leaving questions unanswered and states in the lead. States need to plan to pay for, store, administer, and track the COVID-19 vaccines, all while addressing vaccine hesitancies, ensuring equitable distribution, and addressing budget crises caused by the pandemic. State officials predicted that logistical issues will be worked out, but the messaging and finances require a uniform federal response for best results. NASHP will continue to track state and federal preparation for COVID-19 vaccination distribution and engage states in identifying challenges and developing appropriate policy and programmatic responses.
With Deficits Looming, States Can Use NASHP Template to Track Federal Relief Funds to Hospitals
Hospitals and health care providers need financial support to respond to the pandemic and for future viability. In response, Congress allocated billions of dollars in relief funds through multiple existing and new programs. The disbursement of these funds is uncoordinated and so are public reports that track where the money is going, but states need to know how much these health care systems are getting.
On July 6, 2020, the Small Business Administration (SBA) released Paycheck Protection Program (PPP) loan-level data, which highlighted that health care providers have received more PPP funds than any other industry. Hospitals and physician groups have experienced dramatic revenue loss as a result of states’ stay-at-home orders and their need to rapidly purchase personal protective equipment and establish new safety protocols to confront COVID-19.
States have a clear interest in hospital solvency as a critical community resource and need to know how much large providers have received from the federal government in order to inform their own funding decisions. However, the new PPP data adds to a number of data sources state officials must sift through to track how much support providers in their state are receiving. To better inform their own funding decisions and more easily track these large provider-level distributions, state officials can use this National Academy for State Health Policy’s (NASHP) reporting template to collect the critical information directly from providers. This approach avoids challenges with identifying numerous federal data sources and the technical issues associated with merging data.
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), established the PPP to provide forgivable loans that incentivize businesses to retain employees on their payrolls during the early stages of the COVID-19 pandemic. In addition to the PPP, there have been a multitude of other payments to health care providers through the Families First Coronavirus Response Act, CARES Act, and the Paycheck Protection Program and Health Care Enhancement Act. As the money has been allocated, the federal government has released data about its distribution in a patchwork fashion, making it difficult for state officials to understand which facilities in their communities are receiving funding, from what sources, and for how much. To date, there is data available for the PPP and the Provider Relief Fund for general distributions, high-impact targeted allocations, rural targeted allocations, safety net hospitals, and skilled nursing facility targeted allocations. NASHP is tracking the latest distributions of federal funds in its chart, COVID-19 Federal Funds Earmarked for Hospitals, Providers, and States.
In order for state officials to possibly help support providers during the pandemic, they must have an accurate report of federal investments to date of taxpayer funding to hospitals. This has been challenging due to the necessarily rapid – but at times chaotic – dispersals. Congress allocated funding to multiple federal agencies – the Centers for Disease Control and Prevention, Health Resources and Services Administration, Department of Health and Human Services, SBA, and Treasury Department – which in turn distributed funds through siloed application and reporting systems. In an effort to increase transparency, these agencies have released some data detailing which facilities have received funding thus far. The size of the data files and varying platforms from different agencies may make it difficult for state policymakers to crosswalk the information and identify how much specific facilities have received in aggregate. The PPP data file for entities that received over $150,000 includes over 66,000 entries alone and the Provider Relief fund file has more than 200,000 facilities listed.
The only stakeholders that are able to see the entirety of the funding picture are hospitals and providers themselves – making it necessary for state officials concerned about hospital solvency and the federal and state funding landscape to request the data directly from them. NASHP, in consultation with state officials, recently drafted a template for states to use or revise that seeks timely information detailing which hospitals are already receiving federal coronavirus relief funds. The template seeks information about hospitals and their affiliates that can include labs, physician practices, rural health and behavioral health clinics, surgery centers, and nursing homes. It recognizes that hospitals are under great pressure and as a result is designed for their ease of reporting.
Understanding how much financial support hospitals have or are receiving may become increasingly important as states continue to open up and allow hospitals to perform non-essential services – changing the revenue streams available to hospitals. COVID-19 is proving to be an enduring crisis that will likely require multiple rounds of federal and state support for hospitals. In order for state officials to hold these health systems accountable and help ensure their financial viability in the wake of COVID-19, they may require more robust hospital transparency measures. While this template is an immediate, short-term tracking tool of federal COVID-19 relief funds, NASHP will soon release model hospital transparency legislation designed to provide more specific information about the financial condition of a state’s health care system.
With Federal Funding Fragmented, States Develop COVID-19 Testing Programs for the Uninsured
As states loosen restrictions on stay-at-home orders, many are struggling to establish clear and consistent COVID-19 testing protocols to support individuals’ safe return to work and school and identify ways to pay for increased testing. Absent federal guidance, there is significant debate about who is responsible for funding testing – insurers argue a test must be medically necessary and employers already hard hit by shutdowns contend that paying for testing is a public health obligation.
Multiple federal programs have recently emerged that fund testing, but to date, they primarily cover only the uninsured and there is no clear roadmap for how these fragmented funding streams interrelate and how states should respond. One small piece of the solution appears to rest in state Medicaid programs.
Under the Families First Coronavirus Response Act (FFCRA), states can enroll qualifying uninsured individuals in a new Medicaid eligibility category that covers diagnostic testing and testing-related services, as well as antibody tests. The option is available from March 18, 2020 (when the law was enacted) through the end of the public health emergency period, and states that have chosen this option receive a 100 percent funding match for the new group.
While there is no income limit for individuals to be eligible for the new Medicaid COVID-19 testing group, individuals must meet other qualifying criteria:
- Individuals must be uninsured – not enrolled in private market coverage or in other federal health programs such as Medicare or a mandatory Medicaid eligibility group, with the following stipulations:
- Individuals who are enrolled in short-term limited duration plans are considered to be uninsured for purposes of eligibility for this new group.
- Individuals who live in states that have not implemented the Affordable Care Act’s (ACA) Medicaid expansion but who would have been eligible for the ACA expansion group are eligible for coverage through the COVID-19 testing group if they have no other health coverage.
- Individuals who are enrolled in Medicaid coverage that offers a limited benefit package (e.g., coverage for tuberculosis, family planning-only services, or individuals who qualify as medically needy) are also eligible for the new Medicaid coverage option.
- Individuals must be state residents, provide proof of US citizenship or of a qualifying immigration status, and a Social Security number.
With limited federal guidance available initially – until recent guidance was issued earlier this month – states that chose to implement the option had to take the initiative in determining how to operationalize their enrollment processes for the new eligibility group. States have taken different implementation approaches, depending on the structure of their eligibility determination systems and procedures.
How States Are Implementing the New Medicaid Option
Connecticut opted to build off of its existing eligibility determination processes, and the state now conducts a full assessment of Medicaid eligibility of uninsured individuals seeking coverage for COVID-19 testing. Individuals apply through the state’s Access Health CT portal, which allows for a real-time eligibility determination. While using the complete eligibility determination process results in individuals who are potentially eligible for the COVID-19 testing group receiving notices indicating they are ineligible for Medicaid, the state has developed tailored messaging that informs these individuals that they will be assessed for eligibility for the COVID-19 testing group. State agency staff then use a manual process to evaluate whether these individuals qualify for the testing group. The state also looked back at applications filed since March 18 to identify other potentially eligible individuals and enroll them in the option. Despite requiring additional staff work, this manual part of the process has been fairly manageable because current enrollment is relatively low — about 600 individuals have been enrolled into the new group since the launch of the initiative in early May. In addition to information on the state’s website, state officials have actively publicized the option through provider bulletins, press releases, and outreach to a wide range of stakeholders.
In anticipation of a potential influx of applicants, New Mexico chose to assign the applications for the testing group to a separate unit of eligibility determination workers to prevent regular Medicaid application offices from becoming overburdened. The state created a simplified application for individuals applying for the COVID-19 testing group, and has also developed a memo outlining how providers can bill Medicaid for eligible individuals. To help expedite the establishment of the program, the state chose to use an existing eligibility category code that was already programmed into the state’s system. During the current initial implementation phase, most of the applications have been paper-based. State officials are in the process of developing a mobile-enabled online application to allow individuals to fill out the form on their phones when they are waiting in their cars at testing sites.
In Utah, state officials report they are developing a hybrid eligibility determination process for the new group that will allow for both paper-based and online applications. When the coverage option launched on June 1, 2020, the state began accepting applications through its presumptive eligibility portal tool, which allows for a simplified and streamlined process and a full Medicaid eligibility determination. Individuals will also soon have the option to use a simplified paper application to apply, and the state also identifies potentially eligible individuals from its general pool of denied Medicaid applications. Utah officials are in the process of working with testing sites to enable automatic loading of multiple applications simultaneously into the state’s system. Also, like New Mexico, the state is developing ways for individuals to easily apply for coverage in real time when they are at testing locations.
Multiple, Uncoordinated Sources of Federal Funds Support Testing for Uninsured
A complicating factor for states deciding whether to implement the new Medicaid coverage group is that there are other pools of federal funding for COVID-19 testing, but it is unclear how they are all intended to interact. The COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured Program reimburses providers for COVID-19 testing and treatment claims for uninsured individuals starting on Feb. 4, 2020. Specifically, the program’s FFCRA relief fund contains $2 billion for provider reimbursement for COVID-19 testing of uninsured individuals. Providers are able to submit claims through a portal managed by the Health Resources and Services Administration (HRSA) in order to receive reimbursement equal to Medicare rates. Unlike the Medicaid option, proof of citizenship or a qualifying immigration status is not required. Additionally, the Paycheck Protection Program and Health Care Enhancement Act also established a $25 billion COVID-19 testing fund, of which $1 billion must be used to cover COVID-19 testing for uninsured individuals (this $1 billion was added to the FFCRA Relief Fund, bringing the total of that fund to $2 billion).
Some states have opted not to implement the Medicaid COVID-19 testing group — including Washington State, which already has an approved state plan amendment to do so — because of the availability of reimbursement through the HRSA-administered fund, as well as anticipated operational challenges involved with implementing the Medicaid option. Some of these issues are related to potentially needing to make complex systems changes or complications with the application process, such as obtaining third-party signatures or conducting manual entry of applicants’ data. Another barrier is the potential additional burden on eligibility determination workers overall, who already may be managing a greater number of applications in states where Medicaid enrollment is beginning to increase.
Another consideration for states deciding whether to take up the Medicaid coverage option is that it is unclear how long the HRSA-administered funding will last. This concern about the finite funding through the HRSA portal is cited on Utah’s state webpage as one of the key reasons the state chose to implement the Medicaid testing eligibility group. Other states, such as Connecticut, began efforts to implement the Medicaid coverage option prior to the availability of the HRSA funds. In New Mexico, officials indicated they are not prescriptive in instructing providers how to submit claims for COVID-19 testing and recognize that providers may choose to utilize the HRSA reimbursement process instead of the Medicaid coverage option, particularly because some of the HRSA funding also covers the cost of COVID-19 treatment.
Currently, some states that have implemented the new Medicaid eligibility group are weighing whether to invest more resources to automate enrollment processes for these applicants, but may be hesitant to do so because the coverage category is temporary. While this new Medicaid eligibility group will no longer exist after the end of the public health emergency period, the need for COVID-19 testing of uninsured individuals will remain a pressing issue for the foreseeable future. State officials continue to emphasize the need for greater federal-level recognition and support of states’ testing needs, including testing of asymptomatic individuals, beyond the emergency period and across all health coverage programs.
| Key Federal Funding Sources for COVID-19 Testing and Treatment
|
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| Families First Coronavirus Response Act (FFCRA)
Enacted 3/18/20 |
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| New optional Medicaid eligibility group provides coverage of COVID-19 testing for uninsured individuals | States receive 100% federal medical assistance percentage (FMAP) for testing and testing-related services for enrolled individuals and related administrative costs |
| FFCRA Relief Fund | $1 billion to reimburse providers for testing and testing-related services for uninsured individuals |
| Coronavirus Aid, Relief, and Economic Security (CARES) Act
Enacted 3/27/20 |
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| Provider Relief Fund | $100 billion, primarily to compensate providers for lost patient revenue, but an unspecified amount of the fund is available to reimburse providers for COVID-19 treatment |
| Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA)
Enacted 4/24/20 |
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| Additional funding for Provider Relief Fund | $75 billion in additional funding, bringing Provider Relief Fund to $175 billion |
| Funding for COVID-19 testing | $25 billion – $11 billion for state, local, and tribal governments and $1 billion added to FFCRA Relief Fund to cover testing for uninsured individuals |
States Engage Community Health Workers to Combat COVID-19 and Health Inequities
As recent data shows, COVID-19’s infection and death rates illustrate the profound racial and ethnic disparities in the nation’s health care system and the social and economic inequalities that affect health outcomes. To curb COVID-19 and improve the quality of care delivered to communities that have faced decades of discrimination, a few states are bolstering their community health workforces.
Community health workers (CHWs), are culturally competent, frontline public health workers who are trusted by the communities they serve. Evidence suggests individuals benefit from relationships with people who have similar lived experiences and are members of their community. CHWs are uniquely positioned to build trust and address barriers that traditionally underserved communities face when seeking medical care and services. CHWs can also provide collaborative, patient-centered approaches to care and generate cost savings for state programs.
History of State CHW Initiatives
Before the pandemic, many state programs enlisted CHWs to address challenging aspects of their health improvement initiatives, such as facilitating care coordination, enhancing access to community-based services, and addressing social determinants of health. Payment strategies for CHWs vary; a majority of services are grant-funded with some states reimbursing for CHW services through their Medicaid programs or hiring CHWs as part of managed care organizations.
As states work to address COVID-19, they are bolstering their health care workforces, ramping up contact tracing programs, and finding new ways to fill the gaps in the public health infrastructure created by chronic underfunding. With increased recognition of the adverse health impacts of structural racism, CHWs — who were deemed essential critical infrastructure workers” by the Department of Homeland Security — may strengthen the emergency response and facilitate recovery across demographics.
State Examples of CHW Engagement to Address COVID-19
- Delaware: In May, Gov. John Carney announced a partnership with Healthy Communities Delaware — a collaboration between the Delaware Division of Public Health, the Delaware Community Foundation, and the University of Delaware. The partnership’s goal is to provide linkages between those who test positive for COVID-19 and CHWs, who can help coordinate basic needs like grocery delivery and housing during a period of quarantine. Healthy Communities Delaware is coordinating the effort in partnership with community-based organizations.
- Hawaii: The University of Hawaii is partnering with the Hawaii Department of Health to expand the CHW curriculum at community colleges so that graduating CHWs are equipped to assist with COVID-19 contact tracing efforts. CHWs will specifically help with contact tracing efforts in Native Hawaiian/Pacific Islander communities, which are disproportionately affected by COVID-19, and among individuals facing homelessness and unemployment.. The funding for this initiative was appropriated from Hawaii’s federal CARES Act relief funds.
- Massachusetts: The Office of Community Health Workers recently issued guidance for CHW employers detailing how they can engage CHWs in the state’s COVID-19 pandemic response. The suggestions include cultural competence training and outreach about the virus and its impacts, connecting individuals with community services and supports, and assisting people with the new technologies needed for telehealth appointments. The guidance also acknowledges the increased need for resources, technology, and employer support as CHWs take on a growing and varied number of challenges presented by the pandemic.
Some cities also present promising examples of how CHWs can factor into response and recovery plans. The City of Baltimore is responding to COVID-19’s dual economic and public health crises by creating the Baltimore Health Corps. The pilot program, funded by the CARES Act, the Baltimore City Health Department, the Mayor’s Office of Employment Development, and The Rockefeller Foundation, will hire and train individuals who have recently lost their jobs due to the pandemic to be contact tracers and CHWs. The Health Corps will primarily serve communities that have been disproportionately impacted by COVID-19.
The examples above spotlight how partnerships between different sectors allow cities and states to address the needs of specific populations, to create jobs, and to ramp up their contact tracing workforces. Each addresses the need for equitable care that is delivered by people who understand the lives and challenges of the community they are serving in order to make sure interventions are appropriate and effective. States may want to consider adopting similar strategies along with training their existing CHW workforces for the new challenges of COVID-19 response and recovery.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
