Medicaid Updates: How Eligibility and PHE Changes Impact Urgent Care

As of 04/01/2023, states were able to start processing Medicaid redeterminations and disenrolling residents who no longer qualify for Medicaid. The plans will have 14 months to review the eligibility of their beneficiaries. Additionally, the national Public Health Emergency (PHE) expired on May 11, 2023, which also impacts Medicaid plans.

Yet again, urgent cares must adapt to a “new normal” — one that further complicates an already complex part of the business: revenue cycle management (RCM.) One of our top coding experts, Monte Sandler, Executive Vice President of Revenue Cycle Management at Experity, wrote at length about the impacts of the end of the PHE in this JUCM article. Here we will review changes specific to Medicaid.

Medicaid Eligibility Ending

The Families First Coronavirus Response Act (FFCRA) prevented states from involuntarily removing individuals from their Medicaid coverage. Congress accomplished this by increasing states’ federal Medicaid match rates by 6.2 percentage points. Although initially tied to the Public Health Emergency (PHE), it became part of the federal spending bill passed in December.

As of December 2022, more than 92 million Americans were enrolled in Medicaid, a 31 percent increase since February 2020, according to the Centers for Medicare and Medicaid Services. However, an analysis by the Department of Health and Human Services released in August estimated that around 15 million people could lose their Medicaid coverage once the continuous enrollment requirement ends.

Here are examples of how Virginia and Texas will address this issue.

• Virginia Medicaid will send letters to current Medicaid members via mail containing information about their current health plan, and depending on their status, they may need to take further action, such as updating their contact information.
• Texas Medicaid, on the other hand, will notify Medicaid members via a notice by mail or email, and beneficiaries will need to follow eligibility renewal instructions by visiting YourTexasBenefits.com. The letter will be from the Texas Health and Human Services Commission and will be in a yellow envelope with the words ACTION REQUIRED in red.

Failure to complete these actions will result in loss of coverage. Temporary losses in coverage will occur.

We should expect increased denials. It is imperative that practices check eligibility at time of service and make payment arrangements when appropriate. Patients may not be aware that they lost their coverage.

Help your front desk staff remember to thoroughly check eligibility. Download this customizable front desk checklist PDF >>

COVID-19 Testing, Vaccines, and Treatments

During the PHE, federally regulated health plans were mandated to cover COVID-19 related services, often without cost-sharing — which includes deductibles, co-insurance, and copays.

For Medicaid and Medicaid managed care plans, coverage of coronavirus testing, including at-home, and COVID-19 treatment services without cost sharing ends the last day of the first calendar quarter beginning one year after the end of the PHE (i.e., September 30, 2024).

Beneficiaries in traditional Medicare and Medicare Advantage currently pay no cost sharing for COVID-19 at home testing, testing-related services, and certain treatments, including oral antiviral drugs like Paxlovid. This all ends with the PHE.

Telehealth

The CAA (Consolidated Appropriations Act, 2023) extended the coverage for telehealth services until December 31, 2024, which includes various flexibilities for Medicare and Medicare Advantage plans, such as:

• Coverage in any geographic area, rather than patient’s living in rural areas only.
• Patients can remain in their homes for telehealth, rather than needing to travel to a health care facility.
• Telehealth visits can be delivered via smartphone in lieu of equipment with both audio and video capability.
• The expanded list of Medicare-covered services that can be provided via telehealth will continue.
• Rural health clinics (RHC) can provide telehealth services as a distant site provider, rather than being limited to an originating site.

During the PHE, telehealth services were expanded for Medicaid and Medicaid Managed Plans in all 50 states including the District of Columbia, and states have broad authority to cover telehealth without federal approval. Many states have made or plan to make some Medicaid telehealth flexibilities permanent.

The PHE also temporarily waived some aspects of state licensure requirements, and HHS waived penalties for HIPAA violations against healthcare providers who serve patients in good faith through everyday communications. However, these waivers will end with the PHE. Finally, the ability of providers registered with the DEA to use telemedicine to issue prescriptions for controlled substances to patients without an in-person evaluation will also end with the PHE.

*Note that these cover federal regulations; it is always a best practice to check your state regulations to ensure you stay compliant.

Find more details in the JUCM article.

Get Help With Revenue Cycle Management

Failing to stay on top of changes like these — or the absence of processes to help you catch errors — can lead to costly mistakes in your billing. If you need an RCM partner who knows and understands how these ongoing updates directly impact urgent care, look at Experity. Our urgent-care-specific software and services not only help you be more efficient, but also accurate and compliant. We can even help you navigate contracting/credentialing negotiations and understand the fine print.

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