38 States Have Increased HCBS Payments During the Pandemic

To keep vulnerable Americans at home and out of riskier long-term care settings during the pandemic, the U.S. Centers for Medicare & Medicaid Services (CMS) gave states an unprecedented ability to temporarily modify their Medicaid home- and community-based services (HCBS) programs.

But while the emergency waivers issued by CMS helped limit the spread of the COVID-19 virus, their full impact is largely known, according to a recent report from the Government Accountability Office (GAO).

“CMS relied on states to monitor how these changes affected beneficiaries and make any mid-course corrections — but provided little guidance on doing so,” GAO investors wrote in their report.

GAO is known as the watchdog arm of Congress. Its main responsibility: to evaluate whether key government programs are fulfilling their intended mission.

Knowing little about states’ COVID-era HCBS flexibilities is disastrous for a couple of main reasons, according to GAO. Because CMS hasn’t monitored states closely and checked in on their progress during the current public health emergency, for example, the agency is unable to glean important insights for future ones.

“CMS provided limited guidance to states on monitoring the changes, and did not request that states share any data, such as COVID-19 infections or deaths, with CMS,” the GAO report stated. “Without developing monitoring procedures in advance of future public health emergencies, CMS is unlikely to conduct necessary monitoring.”

A lack of quantitative and qualitative data on the temporary HCBS measures also makes it difficult to evaluate what kind of impact they’d have on a more permanent basis.

Medicaid, a federal-state health financing program for certain low-income and medically needy individuals, directs HCBS to more than 3.6 million beneficiaries per year. Medicaid is the largest single payer for long-term services and supports (LTSS) in the U.S., with the amount of funding going toward HCBS projected to increase moving forward.

“We recommended that CMS evaluate lessons learned from COVID-19 and develop plans for monitoring during future public health emergencies,” noted GAO investigators.

GAO conducted its performance audit from June 2020 to September 2021 in accordance with generally accepted government auditing standards. To do so, the group reviewed “relevant CMS documents” and interviewed multiple agency officials.

State HCBS strategies

In the future, GAO recommended that the U.S. Department of Health and Human Services (HHS) and CMS have systems in place so they can better monitor the impact of temporary flexibilities given out during times of crisis.

The watchdog also urged CMS to conduct follow-up evaluations of the emergency HCBS measures from 2020 and 2021 whenever possible.

“HHS agreed with the importance of monitoring during emergencies, but also noted CMS’s and states’ capacity constraints to do so,” the report continued. “HHS indicated that CMS will conduct an evaluation after the COVID19 emergency to determine the extent to which monitoring is needed for future public health emergencies and will seek state input on any future monitoring plans.”

Beyond highlighting how CMS has kept track of HCBS flexibilities, the GAO report also helps paint a picture of what states have actually done to strengthen in-home care.

According to GAO’s review, 38 states increased payments for certain HCBS organizations, with such bumps designed to cover new costs like purchasing personal protective equipment (PPE) or offering hazard pay. Payment increases ranged dramatically, from as low as $3 million in Rhode Island to $360 million in Washington.

Similarly, 39 states issued payments for providers experiencing service disruptions.

A total of 48 states relaxed provider qualification requirements, including the suspension of criminal background checks for in-home care professionals.

Meanwhile, 42 states allowed HCBS recipients to exceed limits on the amount of care allowed or the number of home-delivered meals they receive in a given period.

Additionally, every state in the U.S. allowed providers to conduct service planning virtually — over the phone or via video — instead of in person.

“To respond to COVID-19, CMS has approved states’ requests to make temporary changes to HCBS programs through an expedited process,” the GAO report described. “With initial guidance from CMS in March 2020, states decided what temporary changes were needed to maintain beneficiaries’ access to HCBS and prevent the spread of COVID-19. CMS has described the number of the changes approved as unprecedented.”

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