California’s Use of Federal and State Policy Flexibilities to Ensure Access to Long-Term Services and Supports During the COVID-19 Pandemic

Introduction

The emergence of the COVID-19 virus has fundamentally shaken the nation’s social, demographic, political, economic, and health care landscapes with two million cases and 115,644 deaths nationally as of June 15.¹ Simultaneously, it has exposed underlying vulnerabilities in systems serving older adults, people with disabilities, and their family caregivers. Older adults have been disproportionately impacted with people age 65 and older representing 80 percent of COVID-19 related deaths, and people age 85 and older representing 32 percent of deaths.¹ In addition, communities that have historically experienced inequities and health disparities have been more severely impacted by COVID-19. For example, Black Americans represent only 13 percent of the U.S. population, but make up 23 percent of COVID-19 related deaths.² With the intersectionality of age, race, gender, and class, risk of severity builds.

California implemented stay-at-home orders in March following the recommendations by public health experts. This significantly impacted older adults and people with disabilities, especially those with high care needs. Social distancing restrictions and bans on visiting people in hospitals, nursing facilities, and assisted living facilities have compounded the impacts of isolation and loneliness experienced by older adults. Prior to COVID-19, 1 in 4 older Americans reported being isolated, and 40 percent reported being lonely. Since March, these numbers have tripled. Research has shown that social isolation substantially increases one’s risk of stroke, heart disease, depression, and dementia.² Individuals who use long-term services and supports (LTSS) are particularly vulnerable to contracting COVID-19 and experiencing severe symptoms due to advanced age and/or living with one or more chronic conditions. Many of these same people are also at risk for nursing home placement. Without access to LTSS in the home and community, many older adults and people with chronic conditions could end up in institutional settings, which have been hardest hit with COVID-19 related deaths. Thus, it is in individuals’ and the state’s best interest to avoid the unnecessary institutionalization of this at-risk population. Federal response to the pandemic has allowed states to request  flexibilities through the Centers for Medicare & Medicaid Services (CMS) in order to continue providing LTSS and mitigate risk. The time frame for the flexibilities depends  on the Secretary of the U.S. Department of Health & Human Services’ public health emergency declaration which can last up to 90 days unless extended.^3,4 In early June 2020, Manatt Health took a broad look across states and identified  ways they have leveraged these new flexibilities to ensure access to LTSS.

California’s Response to LTSS Flexibilities

California’s LTSS system serves individuals both at home and/or in congregate settings (e.g., senior centers, adult day health centers, nursing facilities). For many LTSS programs, the mode of service delivery had to evolve in response to the public health directives. Home- and community-based services (HCBS) operating at congregate sites quickly adjusted to offer services remotely or at an individual’s home. Providers, in partnership with the state, developed alternatives to ensure people could access the support they needed at home while mitigating risk, putting precautions in place, and creating backup systems for providers. California utilized the flexibilities afforded by the federal government to ensure the state’s LTSS system responds to individuals’ evolving needs during the COVID-19 pandemic. At the policy level, tracking California’s implementation of flexibilities enables state leaders to consider how these modifications could shape services and supports in the future. The tables below identify regulatory flexibilities and administrative actions California has implemented that impact where and how LTSS is provided to meet individual care needs during this pandemic. Core themes include virtual care management, access to services, alternate care sites, provider capacity, and consumer protections. To consider flexibilities through a person centered lens, the table includes a statement on Impact on the Person, describing what the care experience might look like for the individual. Each table includes hyperlinks to the different programs and policy authorities. A glossary of acronyms is at the end of the document.

Virtual Care Management

These policy flexibilities and administrative actions seek to ensure individuals can access LTSS while minimizing their risk of exposure to COVID-19 by expanding the use of telehealth in place of in-person visits for care management activities.

Access to Services

These policy flexibilities and administrative actions seek to ensure individuals can access needed services and supports during the pandemic by providing services in new ways, removing prior authorization requirements, and easing administrative requirements.

Alternate Care Sites

These policy flexibilities and administrative actions seek to allow individuals access to HCBS while mitigating risk of exposure to COVID-19 by expanding the allowable settings where HCBS may be provided.

Provider Capacity

These policy flexibilities and administrative actions seek to expand the pool of LTSS and medical providers and workers to ensure individuals can receive services to which they are entitled during the COVID-19 pandemic.

Consumer Protections

These policy flexibilities and administrative actions seek to ensure an individual’s safety and access to services by ensuring continued access to the LTC Ombudsman and adjustments to fair hearing timelines.

Conclusion

The COVID-19 crisis created opportunities for new building blocks of care oriented toward the person-centered experience and outcomes. Learning from the COVID-19 flexibilities, policymakers and providers can consider how these flexibilities might be applied in the future—post COVID-19. To help set a course for permanent LTSS systems change, the flexibilities should be evaluated in relation to California’s Master Plan for Aging goals developed by the Stakeholder Advisory Committee. Additionally, evaluation of the flexibilities alongside person-centered criteria would serve to identify those that have been most impactful in improving care. Such information   could help California determine which flexibilities should remain, be modified, or be removed when the COVID-19 crisis has passed.

Glossary of Acronyms

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