Policies To Enhance Care Of Out-Of-State Pediatric Medicaid Beneficiaries

From Health Affairs Blog 10.6.20

In response to the novel coronavirus (COVID-19) pandemic, the Centers for Medicare and Medicaid Services (CMS) adopted several policies to facilitate beneficiary access to care during this public health emergency. As the pandemic continues, attention is increasingly turning to extending these policies or making them permanent.

Of these temporary actions, one of the most important for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP) has been allowing states to waive various requirements for provider screenings.

Federal law requires that before a provider is able to bill Medicaid, they must be screened by the state Medicaid program and subsequently enrolled in the program as a billing provider. These requirements are designed to prevent fraud, assure program integrity, and establish some of the rules of the road between providers and state programs, and the Medicare program imposes similar requirements. 

As a result, most pediatric specialists are screened and enrolled in both their home state’s Medicaid program and frequently in Medicare. However, the state-by-state nature of Medicaid, particularly state-specific provider screening and enrollment processes, means these providers are routinely asked to enroll and re-enroll in multiple out-of-state Medicaid programs, creating barriers to care for children who must cross state lines.

Recognizing this challenge, all 50 states plus the District of Columbia received the ability to waive certain provider screening requirements under blanket Section 1135 waivers, helping facilitate access to care during the public health emergency. This blog post reviews the challenges providers often face in seeking to care for children from out-of-state Medicaid programs, examines how the flexibilities under the public health emergency have been used to facilitate access, and proposes additional policy reforms that can balance program integrity requirements while facilitating access to care and reducing provider burdens.

Find out more by reading Health Affairs full blog post here