Read this if you are a leader at a state Medicaid agency.
Leveraging Medicaid to support and fund state efforts
In infectious disease control and prevention, contact tracing is the process of identifying people who may have come into contact with an infected person and tracking with whom the infected person has been in contact. The intent is to halt the chain of transmission. State Medicaid Agencies (SMAs) may be able to leverage the Medicaid program to support state efforts with systems, training, and reimbursement for contact tracing.
What is contact tracing?
Tracing the contacts of infected individuals throughout a community, testing their contacts for infection, and treating and quarantining the disease when it is found is a long-standing practice to address infectious diseases. While contact tracing may not be a service that is reimbursable by Medicaid, it may be possible for Medicaid to cover a broader package of services designed to slow the spread of COVID-19.
Contact tracing has three major components:
- Contact identification—Confirmation of an individual’s infection is the first step. Once identified, it is essential to identify any additional people with whom that person came into contact, including family, co-workers, community members, etc.
- Contact tracing—After conducting a complete review of the individual's contacts, outreach begins to inform them of their contact status and discuss critical next steps, starting with testing.
- Contact follow-up—Continued follow-up with identified contacts helps prevent the spread of infection by monitoring spread and/or additional symptoms.
Public health experts maintain that contact tracing is one of the tools needed to manage the pandemic. Medicaid can play a key role in supporting systems, training, and reimbursement for contact tracing. This is enabled through Medicaid’s unique role as a significant payer in the healthcare system, along with its role as a government partnership between federal and state governments. In addition, acting to implement contact tracing may offer an opportunity to increase employment at a time when the economy has shed countless jobs.
Systems and training: Medicaid support for health IT system
To support contact tracing, Medicaid agencies can leverage 75% or 90% federal match or Federal Financial Participation (FFP) for the systems, training, and equipment. This match is applicable for the Medicaid population, while the remainder likely needs to be cost-allocated to other state programs. Activities that can qualify include:
- Design, development, and installation (DDI) of Medicaid solutions. The Centers for Medicare and Medicaid Services (CMS) may allow this funding to apply to data-tracking systems or changes to support new reimbursement models.
- Provider outreach and training related to systems operation, such as training on claims submissions, claims processing, and eligibility inquiries related to case management and care coordination.
- Training of vendor or state personnel directly engaged in the operation of an approved system, including workers processing claims or determining eligibility.
To obtain this type of funding, states must submit an advanced planning document (APD).
Reimbursement: Services and authority options for contact tracing
For Medicaid to support contact tracing, SMAs need to identify both state plan services and authority to provide the service. Defining a service and authority may be challenging, as contact tracing is historically a public health intervention and not a medical service that directly benefits a Medicaid member. CMS does not typically allow this type of service under Medicaid. Given the flexibility afforded under current disaster declarations, however, CMS may have more flexibility than usual. Some options for services include:
Case management
- How it works
First, an individual tests positive and contact-tracing interviews occur. Then, a healthcare provider, such as a hospital, reaches out to the individual, facilitates testing and education, delivers results, and follows up for any care needed. This process applies to any Medicaid members or other individuals who have private insurance that is identified. The provider can discharge the member from case management once the individual recovers. Case management as a Medicaid service is unique in that a diagnosis requiring medical management is the impetus for providing the service.
- Federal approval rationale
Hospitals may be a good partner for this service due to CMS’s Hospital Without Walls guidance. If the hospital partners with the Public Health Entity for contact tracing, then the case management piece could—in theory—be billed by the staff providing case management through the hospital. The hospital would also be able to bill for testing and lab, care, etc. Public Health could track where there is capacity through the medical community for treatment, especially hospital beds, ventilators, and alternative testing sites. The case manager providing coordination of care for COVID-19 testing and treatment would have access to the hospital medical record system, and the hospital could bill for the service.
Health home
- How it works
A health home under the state plan could also serve as a vehicle for services for this population. To better care for Medicaid members with chronic conditions, the Affordable Care Act created an optional Medicaid state plan benefit to coordinate care. Health homes are designed to integrate all physical and behavioral healthcare. Participation in health homes is voluntary. In order for members to participate, they must possess at least one chronic condition (e.g., high blood pressure, asthma, obesity, diabetes, or any serious chronic condition) and be at risk for a second (e.g., COVID-19).
- Federal approval rationale
The health home may be a good support model, as it is eligible for FFP of 90% for the first two years—likely long enough to respond to the pandemic—making it economically attractive.
The most flexible potential authority for a Medicaid agency to use for contact tracing is the 1115 waiver. As part of the Medicaid Disaster Response Toolkit, CMS made expedited review available. In addition, State Medicaid Director Letter (SMDL) #20-002 provides guidance on a new section 1115 waiver available to assist states in addressing the COVID-19 public health emergency.
Section 1115 demonstration waiver
The 1115 waiver is the most dynamic option available, and states can access it through the 1115 disaster waiver option under the Medicaid toolkit. The state may be able to show that providing contact tracing will result in savings for services billed under Medicaid. These savings may be able to be justified by decreasing the number of people who test positive for the virus, leading to budget neutrality. The budget neutrality model would need to show “with” and “without waiver” scenarios that demonstrate to Medicaid the cost of the spread of the virus with and without contact tracing. A challenge to this approach is the time necessary to develop the waiver and budget neutrality model and gain CMS approval.
Recently, CMS approved one of these new section 1115 waivers for the state of Washington. While Washington did not request to cover contact tracing, the speed of approval and the fact that CMS has indicated for the pandemic 1115 requests states will not be required to submit budget neutrality calculations, is a positive indicator for states to consider in envisioning creative models for leveraging Medicaid to minimize the impacts of COVID-19.
Next steps
- Check in with your CMS contacts. COVID-19 is new, and America’s response continues to evolve. Check in with your CMS contact for input on the latest guidance that may be applicable to your agency.
- Develop an APD. Develop your state’s APD to help fund the technology needs for tracking COVID-19, along with training for your SMA team and providers.
- Determine services. In partnership with CMS, determine if case management, a health home, or other service makes the most sense for your state to help trace contacts, reduce the spread of COVID-19, and encourage employment in this important work.
- Submit your waiver for state plan amendment. After working with CMS to determine the service that makes sense for your state, develop and submit the request to provide this service through a 1115 waiver, 1135 waiver, or if necessary, emergency state plan amendment.
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If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team.