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End of the Public Health Emergency

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Public Health Emergency Planning

COVID-19 Public Health Emergency Overview

In Colorado, the Colorado Department of Public Health and Environment (CDPHE) led the public health response to COVID-19. The Colorado Department of Health Care Policy and Financing (HCPF) is the single state agency overseeing Health First Colorado (Colorado’s Medicaid program) and Child Plan Plus (known as CHP+, Colorado’s Children’s Health Insurance program). This document is focused on the HCPF response related to Medicaid/CHIP. For information about the broader public health response visit CDPHE's COVID-19 page.

On January 31, 2020, the U.S. Department of Health and Human Services (HHS) declared a Public Health Emergency (PHE) for the United States to aid the nation’s health care community in responding to the novel Coronavirus Disease (COVID-19). On March 13, 2020, a national emergency concerning the COVID-19 outbreak was also declared. The PHE and national emergencies both allowed for certain flexibilities to respond during an emergency under different areas of federal law. Emergencies can be declared at the state level as well. On March 11, 2020, Colorado Governor Jared Polis declared a state of emergency to respond to the COVID-19 pandemic through Executive Order D 2020 003 Declaring a Disaster Emergency Due to the Presence of Coronavirus Disease 2019 in Colorado. 

The federal Centers for Medicare and Medicaid Services (CMS) also took action to respond to this national public health emergency. Congress subsequently passed several bills signed into law by Presidents Trump and Biden to address the pandemic including: Coronavirus Aid, Relief, and Economic Security Act (CARES), Families First Coronavirus Response Act (FFCRA), and American Rescue Plan Act (ARPA), among others. Examples of major provisions impacting Medicaid are summarized below; this is not an all inclusive list. 

  • The Families First Coronavirus Response Act (FFCRA) included a continuous coverage requirement that allowed people to retain Medicaid coverage and get needed care during the pandemic. The FFCRA allowed coverage to continue as long as the PHE was in place and included enhanced federal matching funds for Medicaid. On December 29, 2022, President Biden signed into law the Consolidated Appropriations Act, 2023 (CAA), an omnibus funding package that decoupled the continuous coverage provision from the end of the COVID-19 PHE. This federal law required all states, including Colorado, to return to normal eligibility operations including disenrollments where appropriate. The CAA also included a gradual phase down of the enhanced federal matching rate and new guardrails to prioritize coverage retention and smooth coverage transitions during the return to normal operations or “unwinding.”
  • Coronavirus Aid, Relief, and Economic Security Act (CARES) and American Rescue Plan Act (ARPA) provided additional emergency funding for providers, enhanced federal funding opportunities for states and local governments to respond to the COVID-19 pandemic including to support Home and Community Based Services (HCBS). Information about Colorado's HCBS ARPA spending plans can be found on the ARPA webpage. 

The federal PHE, which could be extended for up to 90 days at a time, was extended 13 times from January 2020 to most recently in February 2023 for 90 days through May 11, 2023.

Conclusion of COVID-19 National and Public Health Emergencies

In December 2022, Congress passed the CAA to allow states to move to normal eligibility operations and subsequently passed a resolution ending the COVID-19 national emergency. The Biden Administration ended the PHE May 11, 2023. 

The end of the COVID-19 national emergency is separate from the COVID-19 PHE. The ending of a national emergency meant that states could no longer submit new COVID-19 emergency waivers under section 1135 of the Social Security Act granting emergency authority. HCPF’s current waivers remain tied to the HHS PHE. Flexibilities for Home and Community Based Services (HCBS), authorized by 1915(c) Appendix K, are also tied to the COVID-19 PHE.

Colorado's disaster declaration ended May 4, 2023.

 

Colorado and COVID-19 Emergency Federal Flexibilities Overview

At the beginning of the COVID-19 PHE, Colorado, like many other states, pursued federal flexibilities available to states to respond to the pandemic. Colorado pursued several program flexibilities through various types of emergency authorities - known as “waivers."

The two primary types of waivers states used provide for flexibility for State Plan authorized services: waivers of sections 1115 and 1135 of the Social Security Act. There is a special emergency authority called “Appendix K” amendment that allows for additional flexibility for section 1915 (c) Home and Community Based Services (HCBS) Waivers. Appendix K is used by states to advise the Centers for Medicare and Medicaid Services (CMS) of expected changes to a state’s waiver operations or to request an amendment to its approved waiver programs during an emergency. 

Colorado was proactive in asking for flexibility to respond to the pandemic from the federal government. We submitted our first request in the form of an 1115 Waiver and asked for additional flexibility for our ten HCBS waivers on March 13, 2020, before many other states and before the federal government had finalized its preferred process for requests. We submitted the 1135 waiver on March 24, 2020. CMS responded with partial approvals for various elements of the requests on March 26, 2020. Full approvals came later as the federal government finalized its preferred processes approving 1135 waivers but not 1115 waivers for states. Development of a waiver usually takes months; HCPF completed our waiver request in days given the urgency of COVID-19. Colorado submitted and received approvals for 17 Appendix K amendments for our 1915(c) HCBS waivers over the three years of the pandemic.

One example of how an emergency flexibility was used included use of a State Plan Amendment to provide an advanced loan and grant program to 54 clinics that stayed open during the beginning of the pandemic to care for members. The total funding given was $2.5 million dollars. 

Which Flexibilities Did Colorado Use?

Early in the pandemic, Colorado was not sure which emergency flexibilities would be needed, so our requests were broad; some of the flexibilities were never used as we learned more during the pandemic response.  Other emergency flexibilities were made permanent over the course of the pandemic. While many emergency provisions have been made permanent and others are still under consideration by CMS for extensions, some provisions will end or roll back at various times after the PHE ends per federal requirements.

Below is an overview of what temporary program flexibility was requested, what was used, what policy changes were made permanent and what will be changing at the conclusion of the COVID-19 PHE. HCPF will be communicating changes to impacted providers, case managers, stakeholders and members through our member communications, provider bulletins, billing manuals, operational and policy memos, websites and other stakeholder communications as timelines are finalized. Some provisions could still change as additional federal guidance is received.

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Overview of COVID-19 Emergency Federal Flexibilities - Colorado Medicaid

Emergency Policy Flexibilities Made Permanent

Emergency Flexibility Summary

Federal Authority (either Waiver or Federal law)

Did Colorado use this flexibility?

Telehealth Services

Colorado’s General Assembly passed SB 20-212 to make many telehealth services permanent. The federal government approved updates to Colorado’s coverage.

Yes

Telehealth Options for:

  • Life Skills Training
  • Independent Life Skills Training
  • Supported Employment
  • Mentorship
  • Movement Therapy
  • Community Connector
  • Palliative Services
  • Behavioral Services
  • Mental Health Counseling
  • Substance Abuse Counseling
  • Transition Support Services
  • Peer Mentorship
  • Behavioral Management and Education 

Social Security Act §1915(c)

Yes, 5,400 members utilized telehealth for these services during the PHE.

Remote Support Technology added to SLS, EBD, BI, CIH, and CMHS waivers

Social Security Act §1915(c)

Yes

Minimum age for attendants in CDASS and IHSS amended from 18 to 16. 

Social Security Act §1915(c)

Yes

Modification to Level of Care Evaluations and Reevaluations 

  • Qualifications for case managers conducting the Level of Care evaluation was expanded to include relevant experience 
  • Excluding the Professional Medical Information Page (PMIP) from yearly reassessment evaluations 
  • Case managers may use phone or telehealth to engage in the development and monitoring of Person-Centered Service Plan when there is a documented safety risk to the case manager or member 

Social Security Act §1915(c)

Yes

HCPF implemented a base wage requirement of $15/an hour through a rate increase for HCBS direct care workers

Social Security Act §1915(c)

Yes

Virtual Case Management when there is a documented health and safety risk 

Social Security Act §1915(c)

Yes

Modification of Incident Reporting Requirements when the member must evacuate their current setting. 

Social Security Act §1915(c)

Yes

Modification of Adult Day Service to include 15-minute unit increments instead of half-day units. 

Social Security Act §1915(c)

Yes

Tiered rate for Specialized Habilitation and Supported Community Connector for flexible billing. 

Social Security Act §1915(c)

Yes
Public Health Emergency Policy Flexibilities Ending May 11, 2023

Emergency Flexibility Change

Federal Authority (either Waiver or Federal law)

Did Colorado use this flexibility?

COVID-19 testing and treatment to uninsured individuals will no longer be available as of May 31, 2023.* This program was specifically designed for individuals not eligible for Medicaid and without other coverage.

*COVID-19 testing in a doctor's office (not at home kits) and treatment will remain fully covered for individuals who qualify for Medicaid and CHP+.

FFCRA as amended by CARES

Yes, more than 6,000 uninsured Coloradans enrolled for COVID-19 testing or treatment during the pandemic

Non-Emergent Medical Transportation benefits revert back to restrict service to only enrolled locations.

Sections 25.5-1-301 through 25.5-1-303, C.R.S. (2022);

Yes, providers were able to take members to non enrolled sites, like mass vaccination sites get a vaccine and from field hospitals back home. 

Temporary Ambulatory Surgical Center (ASC) rate increases for chemotherapy port placement will revert to the regular rate.

Social Security Act §1135(b)

Yes

Prescription cough and cold medicine will need prior authorization for members 21 and older.

Social Security Act §1135(b)

Yes

Pharmacies will no longer be able to request an early refill override for reasons related to COVID-19.

Social Security Act §1135(b)

Yes

Health First Colorado will no longer defer medication prior authorization requirements for members on all medications for which there is an existing 12-month prior authorization approval in place.

Social Security Act §1135(b)

Yes

Pharmacies cannot request a quantity limit override for medication related to the treatment or prevention of COVID-19.

Social Security Act §1135(b)

Yes

Patients are again required to sign for prescriptions as proof of delivery.

Social Security Act §1135(b)

Yes

Level 1 and Level 2 Pre-Admission Screening and Resident Review (PASRR) assessments will no longer be waived.

Social Security Act §1135(b)

No, Colorado did not use this provision.

Providers who were enrolled as temporary Health First Colorado providers will no longer be able to provide services until they have fully enrolled as a Health First Colorado provider. 

CMS allowed providers to temporarily enroll during the PHE. 

Over the pandemic more than 28,000 new providers enrolled. HCPF is working to convert providers who were temporarily enrolled to fully enroll before November 11, 2023. 

Provider revalidations will resume with an additional six months lead time to allow for notification to the provider of their new revalidation due date. 

CMS put a temporary pause during the PHE on provider revalidations.

Yes, HCPF paused the provider revalidation process during the pandemic but to keep our provider information updated we encouraged providers to complete the process. Providers who missed their revalidation date were not disenrolled. The process, including provider disenrollments where appropriate, will resume as part of returning to normal operations. 

Hospitals will no longer be able to provide inpatient subacute care related to COVID-19 treatment.

Social Security Act, Section 1902(a)(13), 1923 / 42 CFR 447.252

No, since Colorado did not open field hospitals for COVID-19 treatment, this flexibility was never used.  Colorado did prepare for this possibility early in the pandemic.
Public Health Emergency Policy Flexibilities Ending November 11, 2023
For more information on Unwinding Appendix K Flexibilities see Policy Memo 23-003

Emergency Flexibility Change

Federal Authority (either Waiver or Federal law)

Did Colorado use this flexibility?

The Department will no longer allow Day Treatment to be provided using the telehealth option under the Brain Injury (BI) waiver. Additionally, Prevocational Services and Behavioral Health-Line Staff under the Supported Living Services (SLS) and Developmental Disabilities (DD) waivers will no longer be provided using the telehealth option.

Appendix K Amendment allowed this temporary flexibility - the federal government is not allowing states to continue this.

Telehealth was never utilized for Day Treatment in the BI waiver, it was utilized for the SLS and DD waivers.

During the Public Health Emergency, CMS temporarily permitted family caregivers or legally responsible individuals to receive payment for providing certain services.

Appendix K Amendment allowed this temporary flexibility- HCPF has applied with the federal government to extend this flexibility past the November 11, 2023 end date. The Department has requested a January 1, 2024 effective date for permanent adoption. Learn more: IM 23-034.

Yes

Case Management Changes

  • Reinstate Level of Care Assessment to be completed in person.
  • Remove authorization to accept verbal signatures, physical and digital signatures will continue to be accepted.

Appendix K Amendment allowed this temporary flexibility- the federal government is not allowing states to continue this.

Yes
Public Health Emergency Policy Flexibilities Ending September 30, 2024

Emergency Flexibility Change

Federal Authority (either Waiver or Federal law)

Did Colorado use this flexibility?

Vaccines will be paid for by the federal government at 100% for Medicaid enrolled for one year. (COVID-19 vaccines will be a covered benefit, without member co-pay, permanently.)

ARP Section 9811 and Section 9821: Coverage of COVID-19 Vaccines, Vaccine Administration, Testing, and Treatment in Medicaid and CHIP

Yes

Fee-for-service reimbursement for COVID-19 vaccine administration outside of Federally Qualified Health Center (FQHC) encounter payment will be temporarily extended for one year.

ARP Section 9811 and Section 9821: Enhanced Federal Matching Funds for COVID-19 Vaccines and Vaccine Administration; and Colorado State Plan Amendment (SPA) CO-22-0024

Yes

In addition to the flexibilities outlined in the chart above, HCPF has requested permanent approval for telehealth to be included as an option for the Day Habilitation service in our current waiver amendments for the DD and SLS waivers.

HCPF suspended premiums for the Medicaid-Buy In programs through the 12 month (14 months including noticing) unwinding of the continuous coverage requirement.  HCPF will send Buy-In members noticing before premiums resume.  Additional information about the end of the continuous coverage requirement including stakeholder frequently asked questions are available online.    

As federal approvals are finalized our member communications, provider and case manager guidance will be revised.  Please visit our COVID-19 landing page and PHE Planning resource center for links to additional information. Operational guidance, provider bulletins and billing manual updates will be posted on these webpages.

Examples of Important Changes for Members

Health First Colorado members can find information about the end of the continuous coverage requirement, including helpful tips on renewals on the Health First Colorado website. Members can always check their renewal date online through PEAK.

Members will benefit from several other pandemic policy changes becoming permanent including: 

  • Phone and video visits will continue to be covered for all Health First Colorado and CHP+ members. Check with your provider to see if they do phone or video visits. You can use phone and video visits for routine medical care, therapy and other visits.
  • Pharmacists and other pharmacy licensed staff will continue to be able to order and administer COVID-19 vaccines for adult members, and tests and therapeutics for all members.
  • Nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNSs) can continue to order home health services. 
  • COVID-19 vaccines are a permanent benefit, without co-pay.

These services will stop at the end of the PHE on May 11, 2023:

  • Health First Colorado members that are 21 years of age or older can no longer get prescription cough and cold medication without prior authorization from a doctor. 
  • Health First Colorado will no longer defer medication prior authorization (PA) requirements for members on all medications for which there is an existing 12-month PA approval in place.
  • Patients will be required to sign for prescriptions as proof of delivery again. 
  • Pharmacies will no longer be able to request an early refill override for reasons related to COVID-19.
  • Pharmacies will no longer be able to request a quantity limit override for medication related to the treatment or prevention of COVID-19.
  • Pharmacists practicing within a pharmacy will no longer be able to administer COVID-19 vaccines to members under 19, unless their pharmacy enrolls as a Vaccines for Children (VFC) provider. 
  • Non-Emergent Medical Transportation benefits will resume restricting service to only enrolled locations.

Examples of Important Changes for Providers

Provider Revalidation

CMS has provided guidance for states that have temporarily paused revalidation work per their 1135 waiver approval and revalidation work is expected to resume with the end of the PHE. For those revalidation due dates that occurred during the PHE, Colorado may delay the revalidation due date by the amount of time the PHE was in place with an additional six months lead time to allow for notification to the provider of the new revalidation due date.

Effective November 12, 2023, the flexibility that paused disenrollment for providers past their revalidation date during the COVID-19 Public Health Emergency (PHE) is ending. Providers with revalidation due dates of October 1, 2020, through November 11, 2023, will be given a post-PHE grace period to complete the revalidation process. Health First Colorado (Colorado’s Medicaid Program) will notify providers in the coming weeks of their new revalidation date. Providers will be sent another notification 6 months prior to their revalidation date.

Providers with revalidation due dates between October 1, 2020, through November 11, 2023, with no claims activity in the last 3 years must revalidate by November 11, 2023.

Providers that do not complete the revalidation process by their revalidation due date will be subject to claims denial or disenrollment. 

Providers with revalidation applications that are ‘in process’ must complete the process by November 12, 2023, or by their revalidation date, whichever comes first. 

To learn more about the provider revalidation process and how to prepare, visit the Revalidation page.

Conclusion and How to Stay Informed

The PHE Planning Resource Center will be updated as new information about the end of COVID-19 public health emergency and other COVID-19 policy evolves. Changes may take place over time and we will be communicating to the providers or partners that are impacted by those changes. To stay informed about the latest updates, sign up for the COVID-19 public health emergency updates monthly newsletter. 

In addition to the policy changes connected to the end of the public health emergency, HCPF has developed extensive partner toolkits regarding the end of the continuous coverage requirement. Update Your Address, Understanding the Renewal Process and Take Action on Your Renewal toolkits all include resources to help members take action to keep their coverage. A new joint webpage KeepCOCovered.com includes partner resources and information for those who may need to transition to other coverage.