Sep 23, 2020 | Medicaid & CHIP

Overview                                                                                                                                          

To monitor the impact of the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) is releasing its first ever preliminary data snapshot focusing on the impact of COVID-19 on service utilization for children age 18 and under enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). This analysis is essential to understanding the broad ranging impacts of COVID-19, as Medicaid and CHIP cover nearly 40 million children, including three quarters of children living in poverty^[1] and many with special health care needs that require health services.^[2]  The preliminary findings contained in this data snapshot show that, while some data suggest that children may have less severe illness from COVID-19 compared to adults, their service utilization across many key domains, such as primary, preventive, dental and mental health services, has dropped over the past few months.

CMS’s release of COVID-19 data for children enrolled in Medicaid and CHIP is a major step toward sharing timely data on some of the nation’s largest and most important health insurance programs. These results are essential for ensuring not only robust monitoring and oversight of Medicaid and CHIP, but also understanding the impact of the PHE on children and highlighting the distinct result COVID-19 has had on children’s service utilization. By using these results, CMS, states, and other key stakeholders can help drive better health outcomes for some of our nation’s most vulnerable beneficiaries and ensure that children receive the care they need. 

Findings                                                                                                                    

The preliminary data shows that beneficiaries age 18 and under enrolled in Medicaid and CHIP had relatively low treatment rates due to COVID-19. Although more than 250,000 children enrolled in Medicaid and CHIP were tested for COVID-19 through June 2020, only about 32,000 received treatment for COVID-19 and fewer than 1,000 were hospitalized for COVID-19 through the end of May.

However, even though treatment rates for COVID-19 in children appear lower than for other age groups, while enrollment in Medicaid and CHIP has simultaneously increased, we have observed a decline in service use among this population across a number of key domains. When compared to data from the same time period last year (March through May 2019), preliminary data for 2020 shows 1.7 million (22%) fewer vaccinations for beneficiaries up to age 2, 3.2 million (44%) fewer child screening services, 6.9 million (44%) fewer outpatient mental health services even after accounting for increased telehealth services, and 7.6 million (69%) fewer dental services.

Data Sources & Definitions                                                                                                                 

Medicaid and CHIP providers, managed care agencies, and Pharmacy Benefit Managers submit administrative claims data to state Medicaid and CHIP agencies for processing. Those state agencies subsequently submit the data to CMS on a monthly basis via the Transformed Medicaid Statistical Information System (T-MSIS), a uniform, national data system for Medicaid and CHIP. Because T-MSIS submissions are difficult to analyze due to their large size and complex relational structure, CMS developed the research-optimized T-MSIS Analytic Files (TAF) to facilitate the analysis of Medicaid and CHIP data. Additional information about TAF can be found here. This data snapshot utilizes the 2020 TAF to monitor ongoing outcomes related to COVID-19, including measures of Medicaid and CHIP enrollment, COVID-related treatment, and service use. Due to claims submission lags related to state processing and submission via T-MSIS, this analysis primarily focuses on service utilization and health outcomes through the end of May 2020. 

CMS measured enrollment, forgone care, and COVID-related treatment using the following logic:

Enrollment: This analysis includes records for every beneficiary who has any Medicaid or CHIP enrollment record in a given month and is under the age of 19, regardless of the scope of their benefits.

Vaccinations: Vaccinations are identified CPT codes. The vaccines included in this analysis are DTaP, Polio, MMR, Hepatitis B, Hib, Pneumococcal conjugate, Chickenpox, Hepatitis A, and Rotavirus.

Child screening services: Child screenings are identified by two types of codes in claims. The first type is Current Procedural Terminology (CPT) codes that are specific to visits by new or established patients (99381-99385 or 99391-99395) and to initial hospital or birth center care for newborns (99460, 99461, 99463). The second type is general CPT codes for new (99202–99205) or established (99213–99215) patients along with a diagnosis code indicating that the service was provided to a child younger than 19 (e.g., Z00.110 Health examination for newborn under 8 days old).

Dental Services: Dental services are defined on the basis of the Current Dental Terminology (CDT) and CPT code groups from standard annual reporting of the states’ participation in the Early and Periodic Screening, Diagnostic and Treatment program (CMS-416).

Mental health services: Mental health services are identified by claims in which the diagnosis is a mental health condition. In addition to diagnosis, the services are grouped on the claim by type, with this analysis focusing on outpatient claims.

Telehealth: Telehealth is identified through a combination of procedure codes and procedure code modifiers.

COVID testing services: All COVID-19 testing services are grouped into three categories: diagnostic testing, antibody testing, and specimen collection. Diagnostic testing indicates whether an individual has COVID-19. Antibody testing is designed to detect antibodies produced in response to being previously exposed to COVID-19. Specimen collection is the process of obtaining the samples that are necessary to test for COVID-19. Diagnostic testing is identified via Healthcare Common Procedural Coding System (HCPCS) codes U0001, U0002, U0003, and U004 and CPT code 87635. Antibody testing is identified via CPT codes 86328 and 86769. Specimen collection is identified via HCPCS codes G2023 and G2024.

COVID-19 treatment: We use the following International Classification of Diseases (ICD), Tenth Revision (ICD-10), diagnosis codes to identify beneficiaries who received treatment for COVID-19:

• B97.29 (other coronavirus as the cause of diseases classified elsewhere) – before April 1, 2020
• U07.1 (2019 Novel Coronavirus, COVID-19) – from April 1, 2020 onward. 

Although CMS does use lab claims for identifying COVID-19 treatment, CMS does not receive lab results from states and cannot determine whether a lab test was positive. Therefore, Medicaid & CHIP COVID-19 cases are only identifiable in TAF data when there is a corresponding COVID-19 related service.

Key Considerations                                                                                                                          

Readers should use caution when interpreting these results as CMS collects Medicaid and CHIP data for programmatic purposes only, not for public health surveillance. Given the complex process of states collecting, processing, and transmitting claims via T-MSIS, it can take nearly 7 months for CMS to receive 90% of claims. Therefore, this delay between when a service occurs and when it is reflected in TAF, or the “claims lag,” may impact the accuracy of the results. The length of the lag depends on the submitting state, claim type, and delivery system. It is possible that there is a longer claims lag due to the pandemic. Further, in addition to claims lag, states vary widely in terms of the completeness and accuracy of their T-MSIS data submissions. Additional information about state data quality can be found here and here. 

Next Steps                                                                                                                                         

CMS is committed to working with our state partners to help close these gaps in Medicaid and CHIP children’s healthcare, and we will continue to monitor both the direct and indirect impacts of COVID-19 on the Medicaid and CHIP populations using TAF data.

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Source: U.S. Department of Justice.

https://www.justice.gov/opa/pr/william-m-kelly-md-inc-and-omega-imaging-inc-agree-pay-5-million-resolve-alleged-false-claims

U.S. Department of Justice issued the above News Release on September 9, 2020.

News: 2020 Press Release

LOS ANGELES, Calif. — To assist Californians displaced by the current and recent wildfires throughout the state, Insurance Commissioner Ricardo Lara issued a Notice to all California property and casualty insurance companies urging them to cover Additional Living Expenses (ALE) for those policyholders who remain under mandatory evacuation or whose homes are otherwise inaccessible or uninhabitable due to the wildfires.

“When people are told to get out of harm’s way by first responders, they should be able to access insurance benefits, not be forced to pay out of pocket for necessary emergency costs when they are still under evacuation orders or without water or power,” said Commissioner Lara. “While I have sponsored legislation to address this issue, people need help now to recover from these devastating fires.”

All homeowners’ insurance policies provide benefits for loss of use or ALE to cover the extra costs associated with temporary lodging, transportation, clothing, and other necessities caused by a covered peril, such as a wildfire, that renders the home uninhabitable or inaccessible. Homeowners’ insurance policies also cover ALE if access to the home is restricted in cases where a civil authority has issued mandatory evacuation orders from the recent and ongoing wildfires impacting most of the state.

“When you’ve lost the use of your home due to a disaster, you have a reasonable expectation that the insurance you’ve been paying for will cover your temporary living expenses,” said Amy Bach, Executive Director of United Policyholders. “That’s one of the primary benefits of home insurance. We commend Commissioner Lara for reminding insurers of this very basic, important obligation.”

The Department of Insurance has received numerous complaints from policyholders who are hearing from insurance companies that their ALE benefits are being terminated after the initial two weeks unless the insurance company can verify, or the policyholder can prove, that the policyholder’s property suffered damage due to the fires and is still currently uninhabitable, even though mandatory evacuation orders are still in effect in some areas. The Department has also received several related consumer complaints of ALE benefits being discontinued when their homes are uninhabitable due to lost power or water service as a result of the wildfires.

Commissioner Lara sponsored Senate Bill 872, authored by Senator Bill Dodd, this legislative year to address these and other insurance claims issues following a wildfire emergency. The bill has passed the State Legislature with strong bipartisan support and is now heading to the Governor for his consideration. SB 872 would allow for an extension of the two-week limit that is currently in place, and allow for coverage when a home is not damaged but is otherwise uninhabitable for another reason, such as having no electricity or water service caused by a covered peril. The bill would also require an advance payment of no less than four months for costs for living expenses and mandate an advance payment of no less than 25 percent of a policy limit for lost contents without submission of an inventory form, among other consumer protections.

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Media note:

• Notice on Continuation of Additional Living Expense (ALE) Benefits