Letters & Testimony

Alabama Arise and partners urge Ivey to use every Medicaid tool available to save lives during COVID-19 pandemic

To: Gov. Kay Ivey and Commissioner Stephanie Azar
From: The Undersigned Alabama Organizations
Re: Alabama’s Policy Response to COVID-19
Date: March 19, 2020

Thank you both for your leadership, especially at this critical time. Alabama’s health care system, like most others around the world, is facing severe stresses with the COVID-19 pandemic. Seniors and people with underlying health conditions, including people with disabilities, appear to be at most serious and immediate risk from the virus. Alabamians with low income and those who lack health insurance are also high-risk groups, because their options for responding to the health threat and related challenges are limited. In the best of times, public services that provide health care for the most vulnerable Alabamians form the backbone of the health system that protects us all. A health emergency only heightens the need for Alabama’s state health agencies to be as strong as we can make them.

Federal law gives states wide flexibility in using their Medicaid and Children’s Health Insurance Programs (ALL Kids in Alabama) to respond to health emergencies and other disasters. They can expand eligibility and benefits and take steps to make it easier for people to enroll and stay enrolled. The options below include some that Alabama Medicaid has adopted already, many that could be implemented in short order and some that could be requested now for future use. They are in keeping with the important recognition by Governor Ivey and President Trump that COVID-19 requires a bold, timely and comprehensive response.

A few things to consider:

  • People who are eligible for Medicaid can enroll at any time – the “open enrollment” period is year-round.
  • Alabama Medicaid is a “bare-bones” program that has some of the nation’s most stringent eligibility limits.
  • More than 220,000 Alabamians with low incomes are uninsured. Another 120,000 are struggling to pay for work-based or private plans they can’t afford.
  • President Trump has signed a bill that would give states a temporary 6.2 percentage point increase in its federal share of Medicaid funding. For Alabama, that would mean a boost of $380 million for the one-year period starting retroactively on Jan. 1.
  • The pandemic poses critical challenges for certain groups, including people who depend on long-term services and supports at home and in community-based, intermediate and long-term facilities; people experiencing homelessness; and people with special health care needs related and unrelated to COVID-19.
  • Even if a state took up most or all of the emergency options, there would still be gaps in coverage for people who don’t meet Medicaid’s citizenship and immigration status rules.

Current Alabama Medicaid policies that facilitate emergency response:

  • Alabama Medicaid already uses “presumptive eligibility” (PE) to provide temporary coverage for children, pregnant women and parent/caretaker relatives who are determined by a qualified hospital, on the basis of preliminary information, as likely to be eligible for Medicaid.
  • Alabama Medicaid already uses “express lane eligibility” (ELE) to renew children’s Medicaid eligibility automatically on the basis of income data available from the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF).
  • Alabama already uses the “continuous eligibility” option to provide children with 12 full months of coverage through Medicaid and the Children’s Health Insurance Program (ALL Kids), even if the family’s income increases beyond the eligibility limit during the year.

Eligibility: Expanding coverage for the uninsured

Alabama can immediately expand eligibility by submitting state plan amendments (SPAs), applying for 1115 waivers (expedited on an emergency basis if CMS allows), and amending its section 1915 home- and community-based waivers for long-term care:

  • Governor Ivey can submit a SPA to expand coverage for adults with incomes up to 138 percent of the poverty line with enhanced match (90 percent FMAP).
  • Governor Ivey can submit a SPA to increase eligibility for pregnant women, people with disabilities and seniors at the state’s regular FMAP.
  • Alabama can seek an emergency 1115 waiver for federal authority and matching funds to implement continuous coverage for women enrolled in pregnancy-related Medicaid through 12 months postpartum.
  • Alabama can adopt the “ICHIA” option to provide Medicaid and CHIP coverage to lawfully residing children and pregnant women. States can also provide prenatal care to women regardless of immigration status by extending CHIP coverage to the unborn child.
  • Alabama can eliminate or decrease asset tests for seniors and people with disabilities.
  • Alabama can modify its section 1915 home- and community-based services (HCBS) waivers to increase the number of “slots,” or openings for participants. CMS has a template to facilitate changes in section 1915 waivers. The template can also be used to provide additional services that are needed to address COVID-19.

Enrollment: Ensuring that all eligible people can easily enroll and get coverage

  • Alabama should maximize its use of presumptive eligibility (PE) by expanding the definition of qualified entities to include the state agency, community health centers and other community sites and by adding eligibility for seniors and individuals with disabilities. Alabama should develop a plan for follow-up to ensure eligibility of individuals beyond the PE period.
  • Alabama should outstation eligibility staff to the maximum extent possible.
  • Alabama should enroll people based on their self-attestation and follow up with verification requests only when the attestation is not compatible with electronic data sources.
  • States are required to provide a reasonable opportunity period of at least 90 days to individuals who attest they are citizens or have an immigration status that would make them eligible for benefits, as well as to those who don’t have a Social Security number. This means Alabama should enroll people and assist them in providing any documents they need after exhausting attempts to verify citizenship or status through electronic verification.
  • Alabama should add the school lunch program to the express lane eligibility data-sharing process for Medicaid eligibility.

Renewal: Keeping people covered

  • Alabama should temporarily delay renewals under authority to exceed time limits in emergency situations.
  • Under existing Medicaid rules, Alabama should maintain coverage for people temporarily residing out of state because of the coronavirus.

Benefits: Getting people the care they need

  • Alabama should submit a SPA to take up the option in the Affordable Care Act (ACA) to ensure all necessary treatment and preventive services, including vaccines, are covered for all adults Medicaid beneficiaries without cost-sharing. States that take up this option receive a 1 percentage point bump in the FMAP for those services under section 4106 of the ACA.
  • Alabama should cover 90-day supplies of maintenance medications, allow advance refills and cover home delivery of prescription drugs.
  • Alabama should provide expanded benefits for affected populations through 1915(i) state option for home- and community-based services.
  • Alabama should educate providers on Medicaid coverage, especially the EPSDT benefit for children, guaranteeing that children receive regular screening exams and preventive care and all necessary follow-up diagnostic and treatment services.
  • Alabama should maximize the use of telehealth — including reimbursement for the full range of early intervention, treatment and rehabilitative services — to extend provider access and reduce direct personal contact during the pandemic.
  • Alabama should maximize coverage and awareness of emergency services available to people not eligible for Medicaid due to immigration status.

Continuity of care: Preventing disruption of services for people with special health care needs and disabilities

Thousands of Alabama Medicaid members depend on health services and daily living supports provided in home- and community-based settings and long-term care facilities. For these individuals, disruptions in care and assistance can be life-threatening.

  • Alabama must respect the rights of people with special health care needs and disabilities to make their own choices in all aspects of their COVID-19 contingency plan.
  • Alabama should waive all administrative requirements except federal and state background checks to allow on-the-spot hiring of personal care attendants by people receiving long-term services and supports.
  • Alabama should suspend or waive overtime-limiting regulations for personal assistance services to facilitate continuity of care when illness, quarantine and other factors reduce staff and support network capacity.
  • Alabama should guarantee personal assistance service providers paid sick time to encourage providers to stay home and decrease spreading infection.
  • Alabama should provide funding to community organizations such as Independent Living Centers and developmental disability service providers to establish or expand expedited recruitment processes for emergency backup assistance for all formal and informal, government and non-government supports and services to close COVID-19 gaps and keep people independent.

Bottom line

Use every tool available to protect Alabamians in the short, medium and long term.

These recommendations are adapted from analysis provided by the Center on Budget and Policy Priorities, the Medicaid and CHIP Coverage Learning Collaborative, the Kaiser Family Foundation, Disability Rights & Resources, and Accessible Alabama.


The following organizations respectfully endorse these recommendations:

Accessible Alabama
AIDS Alabama
Alabama Appleseed Center for Law & Justice
Alabama Arise
Alabama Coalition for Immigrant Justice
Alabama Disabilities Advocacy Program
Alabama Faith Council
Alabama-Florida Episcopal District of the AME Zion Church
Alabama Institute for Social Justice
Alabama Justice Initiative
Alabama Poor People’s Campaign: A National Call for Moral Revival
Alabama Rivers Alliance
Alabama Select ICN Consumer Advisory Committee
Alabama State Association of Cooperatives
Alabama State Conference of the NAACP
AME Church of Alabama
Disabilities Leadership Coalition of Alabama
Disability Rights & Resources
Faith and Works
Faith in Action Alabama
Fifth Episcopal District, Christian Methodist Episcopal Church
Greater Birmingham Ministries
Hispanic Interest Coalition of Alabama
Hometown Action
The Knights & Orchids Society
Medical Advocacy & Outreach
NAMI Alabama
National MS Society, Alabama
People First of Alabama
Planned Parenthood Southeast
Save Ourselves Coalition for Justice and Democracy
Sickle Cell Disease Association of America
Southern Poverty Law Center
United Cerebral Palsy of Alabama
VOICES for Alabama’s Children
The Women’s Fund of Greater Birmingham
YWCA Central Alabama