Fact Sheet: Medicaid & CHIP and the COVID-19 Public Health Emergency

Overview

To monitor the impact of the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) conducted extensive data analysis using the Transformed Medicaid Statistical Information System (T-MSIS) Analytic Files (TAF) and is releasing a comprehensive overview of the PHE’s impact on Medicaid and CHIP beneficiaries and service utilization through October 2020. Specifically, CMS is releasing updated data that examines:

• COVID-19 treatment, acute care use, and testing,
• Service use among Medicaid & CHIP beneficiaries age 18 and under,
• Services delivered via telehealth to Medicaid and CHIP beneficiaries, and
• Services for mental health and substance use disorders (SUDs) among Medicaid and CHIP beneficiaries.

These analyses are essential to increasing our understanding of COVID-19’s impacts, as Medicaid and CHIP covered over 100 million Americans for at least one day between January and October 2020, including children, pregnant women, adults, seniors, and individuals with disabilities, among other groups. Within these beneficiary populations, it is particularly important to note that Medicaid and CHIP covered nearly 43 million children during this time, including many living in poverty[1]or with a special health care need,[2] and are the largest payers for mental health services in the United States.[3]

The preliminary findings show that more than 1.2 million beneficiaries have received treatment for COVID-19 through October 2020, with nearly 124,000 hospitalizations. Further, the secondary impacts of COVID-19 on service utilization have been significant. For children, although 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 course of the PHE. Although utilization rates are rebounding in many key areas and across the majority of states, millions of services still need to be delivered to make up for those missed between March and October 2020. For service delivery, there has been a notable increase in the number of services delivered via telehealth compared to prior years, with a peak in April 2020 and a gradual decline since. For beneficiaries with mental health or substance use disorders, service utilization dropped substantially in April 2020 and has continued to decline in nearly all states. Compared to prior years’ rates, there is a notable gap in services for mental health conditions and SUDs.

Taken together, CMS’s release of COVID-19 data is a major step toward sharing timely data on some of the nation’s largest and most important health coverage programs. These results are essential not only for ensuring robust monitoring and oversight of Medicaid and CHIP, but also for highlighting the distinct impact COVID-19 has had on children’s service utilization, telehealth utilization, and services for mental health and SUDs. 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. 

Findings

COVID-19 treatment, acute care use, and outcomes: The results demonstrate distinct results for each thematic domain. For COVID-19 treatment and outcomes, over 1.2 million beneficiaries have received treatment, and nearly 124,000 Medicaid and CHIP beneficiaries have been hospitalized through the end of October 2020. Further, Medicaid and CHIP have paid for more than 9.9 million COVID-19 tests or testing-related services since the start of the PHE, not including tests or testing-related services provided free of charge or covered by other insurance programs, including Medicare.

Service utilization among Medicaid & CHIP beneficiaries age 18 and under: There has been a decline in service use among this population across a number of key domains. When compared to data from the same time period in 2019 (March through October 2019), preliminary data for 2020 show 1.8 million (9%) fewer vaccinations for beneficiaries up to age two, 4.6 million (21%) fewer child screening services, 14 million (34%) fewer mental health services, and 11.4 million (39%) fewer dental services. Although rates across many domains are starting to rebound, millions of services still need to be delivered to make up for those missed between March and October 2020. However, there is considerable state variation in service use rates, with some states returning to or surpassing February 2020 levels of care by June 2020.

Services delivered via telehealth:  The results demonstrate that the number of services delivered via telehealth surged during the PHE, with more nearly 68 million services delivered via telehealth occurring between March and October 2020. This represents an increase of more than 2,700% compared to the same period from 2019. Generally speaking, telehealth utilization increased through April 2020, then began to decline through October, although levels remained substantially higher than prior year levels. Increases were largest among adults ages 19-64, followed by children age 18 and under. Telehealth utilization levels for services paid by Medicaid and CHIP were lowest for ages 65 and older, but the results may not reflect this group’s total telehealth utilization, as many of these beneficiaries are likely dually eligible for Medicaid and Medicare. Therefore, Medicare may have paid for additional services delivered via telehealth that are not reflected in these results. There appears to be substantial variation across states in the number of services delivered via telehealth.

Services for mental health and SUD among Medicaid & CHIP beneficiaries:  There has been a significant decline in service use since April 2020, with declines continuing through October in nearly all states. When compared to data from the same time period from 2019 (March through October 2019), preliminary data for 2020 show 12 million (22%) fewer mental health services for adults age 19 to 64 and 3.6 million (13%) fewer SUD services. Although there is significant variance across states, service utilization rates across both domains appear to be continuing to decline across the majority of states even though preliminary evidence suggests there has been an increase in the number of adults reporting adverse mental or behavioral health conditions during the COVID-19 PHE.[4]

For each set of the results, the estimates reflect services that are covered by Medicaid and CHIP. Services covered by other insurance programs, such as Medicare, are not included in these results. Given that there is a sizable population enrolled in both Medicare and Medicaid, with 12.3 million dually eligible beneficiaries in 2019,[5] the results are unlikely to reflect the full scope of COVID-19 related treatments for dually eligible beneficiaries, as Medicare pays first for Medicare-covered services that are also covered by Medicaid because Medicaid is generally the payer of last resort.[6] For more information about COVID-19 related cases and hospitalizations among dually eligible beneficiaries covered by Medicare, refer to CMS' Medicare COVID-19 Data Snapshot.

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 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 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 October 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, regardless of the scope of their benefits.

Vaccinations: Vaccinations are identified by Current Procedural Terminology (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 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’ provision of Early and Periodic Screening, Diagnostic and Treatment services (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: inpatient, intensive outpatient/partial hospitalization, outpatient, emergency department, and telehealth.

Substance Use Disorder (SUD) services: Substance use disorder services are identified by claims in which the diagnosis is a substance use disorder. In addition to diagnosis, the services are grouped on the claim by type: inpatient, intensive outpatient/partial hospitalization, outpatient, emergency department, and telehealth.

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 laboratory 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, 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 COVID-19 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 state Medicaid and CHIP agencies to help close these gaps in children's health care and in treatment for mental health conditions, 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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