SHO# 20-004 — Planning for the Resumption of Normal State Medicaid, CHIP and BHP Operations
Summary
CMS State Health Official letter SHO# 20-004, Planning for the Resumption of Normal State Medicaid, Children's Health Insurance Program (CHIP), and Basic Health Program (BHP) Operations Upon Conclusion of the COVID-19 Public Health Emergency, from the Centers for Medicare & Medicaid Services in the Department of Health & Human Services, dated December 22, 2020. The letter states that its purpose is to provide guidance to states on planning for the eventual return to regular operations, including ending temporary authorities when the PHE concludes and addressing pending eligibility and enrollment actions. It states that the FFCRA provides states with a temporary 6.2 percentage point increase in the federal medical assistance percentage (FMAP) if they meet certain conditions, including a continuous enrollment requirement for most Medicaid beneficiaries.
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“SHO# 20-004 — Planning for the Resumption of Normal State Medicaid, CHIP and BHP Operations.”
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DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop S2-26-12
Baltimore, Maryland 21244-1850
SHO# 20-004
RE: Planning for the Resumption
of Normal State Medicaid,
Children’s Health Insurance
Program (CHIP), and Basic
Health Program (BHP) Operations
Upon Conclusion of the COVID-19
Public Health Emergency
December 22, 2020
Dear State Health Official:
Introduction
Medicaid and the Children’s Health Insurance Program (CHIP) play critical roles in helping
states and territories respond to public health emergencies and disasters, including the outbreak
of the Novel Coronavirus Disease 2019 (COVID-19). Over the course of the COVID-19 Public
Health Emergency (PHE), state Medicaid, CHIP, and Basic Health Programs (BHP) adopted
many flexibilities offered by the Centers for Medicare & Medicaid Services (CMS) to respond
effectively to their local outbreaks, including changes to modify eligibility requirements and
benefit packages, ensure access to home and community-based services (HCBS), and support
health care providers by updating payment rates. In addition to adoption of these flexibilities,
states made program changes to comply with the requirements of section 6008 of the Families
First Coronavirus Response Act (FFCRA) (Pub. L. 116-127) as amended by the Coronavirus
Aid, Relief, and Economic Security (CARES) Act (Pub. L. 116-136). The FFCRA provides
states with a temporary 6.2 percentage point increase in the federal medical assistance percentage
(FMAP) if they meet certain conditions, including a continuous enrollment requirement for most
Medicaid beneficiaries who were enrolled in the program as of or after March 18, 2020.
Managing the continuing PHE remains a critical priority for CMS, including through our work to
extend provider capacity and to prepare for the availability of a vaccine. The purpose of this
letter is to provide guidance to states on planning for the eventual return to regular operations,
including ending temporary authorities when the PHE concludes, making temporary changes
permanent in certain circumstances, procedures for ending coverage and policies authorized
under expiring FFCRA provisions, and addressing pending eligibility and enrollment actions that
developed during the PHE. 1 CMS’ expectations related to returning to normal eligibility and
1 The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless
specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing
requirements under the law.
Page 2 – State Health Official
enrollment operations are described in Section VI of this letter. States implemented an array of
program and systems changes to best serve beneficiaries during the PHE, and this guidance will
support states in planning for the eventual end of the PHE, ensuring that they are able to
transition back to normal operations when the PHE ends efficiently and in such a way that
minimizes burden for beneficiaries.
Table of Contents
I. Background ................................................................................................................................ 2
II. Resuming Normal Operations Before the End of the PHE and Continuing
Temporary Authorities Beyond the PHE ................................................................................... 5
III. Regulatory Requirements for Concluding Temporary Authorities .................................. 8
IV. Other Requirements for Ending Specific Authorities....................................................... 13
V. Operational and Managed Care Considerations ................................................................ 19
VI. Resuming Normal Eligibility and Enrollment Operations:
Addressing Pending Eligibility and Enrollment Actions ........................................................ 21
VII. Strategies to Support Returning to Routine Operations ................................................. 30
VIII. Program Integrity Considerations ................................................................................... 35
I. Background
During a PHE or disaster, CMS can use various legal authorities to grant states’ emergency
flexibilities critical to ensuring a state’s ability to respond to the crisis expeditiously and protect
and serve the general public. On January 31, 2020, the Secretary of Health and Human Services
(HHS) declared a PHE, effective as of January 27, 2020, for the entire United States to aid the
nation’s healthcare community in responding to COVID-19. On March 13, 2020, the President
declared the ongoing COVID-19 pandemic of sufficient severity and magnitude to warrant an
emergency declaration for all states, tribes, territories, and the District of Columbia pursuant to
section 501(b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42
U.S.C. 5121-5207 (the “Stafford Act”) with a retroactive effective date of March 1, 2020.
As part of CMS’s ongoing efforts to assist states with addressing the COVID-19 PHE, CMS
released new tools to speed states’ access to emergency flexibilities and support state Medicaid,
CHIP, and BHP agencies during the COVID-19 outbreak. CMS created and released four
checklists to help states receive federal waivers and assist them in identifying other authorities in
order to implement flexibilities in their Medicaid and/or CHIP programs more efficiently. These
tools permit states to access emergency administrative relief, make temporary modifications to
Medicaid eligibility and benefit requirements, relax rules to ensure that individuals with
disabilities and older adults can be effectively served in their homes, modify payment rules to
support health care providers affected by the PHE, and provide wider access to Medicaid-
covered services furnished via telehealth. States have the option to request that many of these
waivers, state plan amendments (SPAs), and other mechanisms be made effective retroactively,
to as early as March 1, 2020, the effective date of the national emergency declared by the
President. Many of the options and authorities available to states are described in Appendix A.
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States are also able to take advantage of other flexibilities, including emergency information
technology (IT) funding, CHIP Disaster Relief SPAs, BHP Blueprint revisions, verification
process simplifications, and the flexibility that exists under current regulations related to the
timeliness of eligibility determinations and taking final administrative action on fair hearings.
As of December 17, 2020, CMS received nearly 700 submissions from states for waivers, SPAs,
BHP Blueprint revisions, and other flexibilities, and CMS has approved more than 600 of these
submissions. These approvals provide states the flexibility they need to make program changes
to respond to the PHE.
Authority Effective and Termination Dates
Each temporary authority adopted by states to respond to the COVID-19 PHE is scheduled to
automatically sunset upon termination of the PHE or another specified date. Effective and
termination dates for the various authorities are provided in the table below. On October 2,
2020, the HHS Secretary renewed the COVID-19 PHE. The renewal took effect on October 23,
2020 and extends the PHE for another 90 days. 2
Authority / Provision Effective Date Termination Date
Medicaid & CHIP 1135 March 1, 2020 Expires at the end of PHE.
Waivers
Appendix K of the 1915(c) January 27, 2020 For Appendix K submissions in response to
HCBS Waiver Instructions or any later date the COVID-19 PHE, the termination date
and Technical Guidance elected by state will be no later than six months after the
expiration of the PHE.
Medicaid Disaster Relief March 1, 2020 Expires at the end of PHE or any earlier
SPA for the COVID-19 or any later date approved date elected by state.
PHE elected by state
CHIP Disaster Relief SPA Start of state or Expires at the end of PHE or at state
(specific to COVID-19 federally discretion before end of PHE. 3
PHE) declared
emergency
BHP Blueprint Revisions March 1, 2020 Expires no later than the end of PHE, unless
or any later date a later date is requested and approved by
elected by state CMS.
Medicaid and CHIP Any date elected Expires on a date selected by the state.
Disaster Relief MAGI- by state
Based Verification Plan
Addendum
1115 Demonstration to March 1, 2020 Expires no later than 60 days after end of
Respond to the COVID-19 or any later date PHE.
PHE elected by state
2 Declaration of 90 day extension of the COVID-19 Public Health Emergency (PHE) on October 2, 2020
https://www.phe.gov/emergency/news/healthactions/phe/Pages/covid19-2Oct2020.aspx
3 Some states have the authority to continue CHIP disaster flexibilities through the end of a state declared emergency. If you have
questions about the duration of flexibilities, contact your CMS CHIP project officer.
Page 4 – State Health Official
Legislative Requirements Related to COVID-19
In addition to adoption of the flexibilities described above, states made program changes to
comply with the requirements of section 6008 of the FFCRA, as amended by the CARES Act.
Section 6008 of the FFCRA provides a temporary 6.2 percentage point increase to the FMAP
under the first sentence of section 1905(b) of the Social Security Act (the Act) for states and
territories that meet certain conditions, including that they 1) maintain eligibility standards,
methodologies, or procedures that are no more restrictive than what the state had in place as of
January 1, 2020; 2) do not charge premiums in excess of those in place on January 1, 2020; 4 3)
maintain Medicaid enrollment for certain beneficiaries through the end of the month in which the
PHE ends; and 4) cover COVID-19 testing and treatment services (including vaccines,
specialized equipment, and therapies) without cost sharing. 5 The increased FMAP is available
for qualifying expenditures that were incurred on or after January 1, 2020 and through the end of
the quarter in which the PHE, including any extensions, ends. The continuous enrollment
requirement in section 6008(b)(3) of the FFCRA prevents states seeking to claim the temporary
FMAP increase from terminating eligibility for individuals enrolled as of or after March 18,
2020, through the end of the month in which the PHE ends, even if the individual no longer
meets eligibility requirements, unless the person voluntarily disenrolls or is no longer a state
resident. The requirements of section 6008 of the FFCRA do not apply to separate CHIPs or to
the BHP.
Key Dates for Termination of Conditions for FFCRA FMAP Increase
Key termination dates for the requirements of section 6008(b) of the FFCRA are described
below.
FFCRA Section 6008(b) Conditions for 6.2 Termination Date
Percentage Point Increase for FMAP
Maintenance of Effort (eligibility standards, Expires the first day of the month following
methodologies, procedures) – Section the calendar quarter in which the PHE ends.
6008(b)(1) of FFCRA
Premium Restrictions – Section 6008(b)(2) of Expires the first day of the month following
FFCRA the calendar quarter in which the PHE ends.
Continuous Enrollment – Section 6008(b)(3) Expires the first day of the month following
of FFCRA the month in which the PHE ends.
Coverage of, and Cost-sharing Exemption Expires the first day of the month following
for, COVID-19-related Testing and calendar quarter in which the PHE ends.
Treatment – Section 6008(b)(4) of FFCRA
4 Pursuant to section 6008(d) of the FFCRA, as added by section 3720 of the CARES Act, P.L. 116-136, a state is not ineligible
for the temporary FMAP increase on the basis that it imposed a premium higher than any in effect on January 1, 2020, during the
30-day period beginning on March 18, 2020, if such premium was in effect on March 18, 2020.
5 For additional information on the temporary FMAP increase and conditions for states and territories to qualify for it, see section
6008 of the FFCRA, Interim Final Rule with Comment (IFC) CMS-9912-IFC, “Additional Policy and Regulatory Revisions in
Response to the COVID-19 Public Health Emergency, 85 FR 71142 (Nov. 6, 2020), and Medicaid and CHIP Frequently Asked
Questions, available on Medicaid.gov.
Page 5 – State Health Official
All of the conditions described in section 6008(b) of the FFCRA extend beyond the end of the
COVID-19 PHE, including (in some cases) through the end of the calendar quarter in which the
PHE ends (if the state claims the temporary FMAP increase under FFCRA section 6008 in that
quarter). However, Disaster Relief SPAs expire on the date the PHE expires (and could expire
sooner). Therefore, states may need to amend their underlying state plans to ensure that they are
able to meet the FFCRA section 6008(b) conditions for the entire period during which those
conditions apply. For example, if a state provides for coverage and/or payment of services
required under FFCRA section 6008(b)(4) under a Disaster Relief SPA, and wants to claim the
FFCRA section 6008 temporary FMAP increase in the quarter in which the COVID-19 PHE
ends, it may need another SPA in place to effectuate coverage and payment for those services
through the end of the quarter in which the COVID-19 PHE ends. We note that some states have
elected to apply certain provisions of section 6008 of FFCRA to their separate CHIP programs,
such as covering COVID-19 related treatment without cost sharing, although it is not a
requirement. If a state wishes to maintain this optional coverage in its separate CHIP beyond the
end of the COVID-19 PHE and through the calendar quarter in which the PHE ends, the state
should submit a CHIP SPA. CMS is available to provide technical assistance on these issues.
II. Resuming Normal Operations Before the End of the PHE and Continuing Temporary
Authorities Beyond the PHE
CMS recognizes that the COVID-19 PHE is impacting each state differently and that local
conditions influence the types and duration of emergency flexibilities necessary to ensure access
to health care services and mitigate the spread of COVID-19. To ease the transition back to
normal operations, CMS encourages states to inventory each flexibility it implemented to
address the COVID-19 PHE to determine whether the flexibility should end prior to the end of
the PHE, be maintained for the duration of the PHE, or be extended on a temporary or permanent
basis after the PHE concludes, as allowable (to be determined on a case-by-case basis).
Resuming Normal Operations Before the End of the PHE
As local outbreak conditions evolve, states may no longer need to utilize all of the temporary
authorities granted to them. CMS recommends states consider transitioning back to normal
operations in a phased approach as individual flexibilities are no longer needed to address the
COVID-19 PHE. For example, many states received concurrence from CMS that the PHE
represents an emergency triggering an exception to meeting federal timeliness standards for
processing Medicaid, CHIP, and BHP applications and redeterminations. However, states
should begin processing these actions to the extent possible before the PHE ends to ensure they
are able to comply with timeliness standards upon conclusion of the PHE. Additionally, some
states received 1135 waiver authority for a 30-day delay of Pre-Admission Screening and Annual
Resident Review (PASRR) Level I and Level II assessments. In recognition of the role PASRR
plays in diverting unnecessary nursing facility stays or facilitating transitions out of nursing
facilities for individuals with a mental illness or developmental disability, CMS encourages
states to return to timely PASRR activities as quickly as possible. In addition, CMS reminds
states that they continue to have independent obligations to comply with the Americans with
Disabilities Act, Section 1557 of the Patient Protection and Affordable Care Act, and Section
Page 6 – State Health Official
504 of the Rehabilitation Act, including their requirements under Olmstead v. L.C., 6 which
remain in effect during this public health emergency. Technical assistance is available from the
HHS Office for Civil Rights and the Department of Justice Civil Rights Division.
Extending Temporary Flexibilities Beyond the PHE
States may find that some flexibilities may be useful to extend on a temporary or permanent
basis. For example, some states implemented temporary state plan changes to provide
alternative payment and coverage for services furnished using telehealth. Other states allowed
the temporary use of telehealth in their 1915(c) waivers, such as for personal care services that
only require verbal cueing, using Appendix K. A state may choose to incorporate this service
delivery modality into its post-PHE activities by amending their state plans or 1915(c) waivers,
as described below. Additionally, a number of states received authority to pay COVID-19
laboratory testing services at 100 percent of Medicare rates, which differs from payment rates
for other laboratory services in the state plan. Such states may elect to temporarily extend this
payment policy beyond the end of the PHE by amending their state plan.
• Extending SPA Authorities and BHP Blueprint Revisions: States seeking to extend one
or more Medicaid or CHIP state plan authorities or BHP Blueprint revisions approved to
address the COVID-19 pandemic beyond the PHE must submit a SPA or Blueprint
through the regular SPA or Blueprint revision process. States must comply with all
regulatory and statutory requirements for submission of these regular SPAs and BHP
Blueprint revisions, including 1) limitations on effective dates at 42 C.F.R. §430.20 for
Medicaid SPAs, §457.65 for CHIP SPAs, and §600.125 for BHP Blueprint revisions; 2)
tribal consultation requirements described in the state plan and at sections 1902(a)(73)
and 2107(e)(1)(F) of the Act and §600.155; and 3) public notice requirements at
§457.65(b) for CHIP SPAs 7 and §600.115(c) for BHP Blueprint revisions, where
applicable. Additional information on extending Medicaid state plan authorities may be
found at: https://www.medicaid.gov/state-resource-center/downloads/allstatecall-
20200616.pdf. Details on extending CHIP state plan authorities may be found at:
https://www.medicaid.gov/state-resource-center/downloads/allstatecall-20200623.pdf.
• Updating Verification Processes: States can extend or adopt new changes to their
Medicaid and CHIP verification processes provided that the changes are consistent with
federal statute and regulations at 42 C.F.R. §435.940 through §435.960 and §457.380.
Any changes must be documented in the state’s internal policies and procedures. States
must also update and submit changes to verification plans for Modified Adjusted Gross
Income (MAGI)-based populations to CMS, consistent with 42 C.F.R. §§435.945(j) and
457.380(j). For temporary changes, states may submit a revised verification plan
addendum, which may be found at:
https://www.medicaid.gov/medicaid/eligibility/downloads/magi-based-verification-
6 Under title II of the ADA and the Supreme Court’s Olmstead v. L.C. opinion, the unjustified isolation of individuals with
disabilities constitutes unlawful discrimination. States are required to provide community-based treatment where such treatment
would be appropriate, the affected person does not oppose such treatment, and the treatment can be reasonably accommodated.
Further information on state obligations under Olmstead can be found at https://www.ada.gov/olmstead/q&a_olmstead.htm.
7 We note that federal CHIP regulations in 42 CFR 457.65(b) only require public notice if the SPA eliminates or restricts
eligibility or benefits. States should also follow any state laws related to public notice.
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plan-addendum-template.docx. To notify CMS of indefinite changes to MAGI-based
verification processes, states would submit a revised verification plan.
• Extending Section 1915(c) Appendix K Flexibilities: Termination of Appendix Ks for
section 1915(c) waivers, unlike other authorities, is not typically tied to the end of the
PHE declared by HHS, but instead to the end date specified in the Appendix K
approvals. Many states’ approved Appendix K authorities related to the COVID-19
PHE are currently set to terminate during the first quarter of 2021. States should
routinely assess whether flexibilities will be needed beyond their specified termination
date, and they may seek CMS approval to extend or modify their Appendix K
flexibilities if necessary. If needed, states may submit an updated Appendix K
application to extend or modify the end date. In recognition of the uncertainties
associated with the period of time in which the COVID-19 PHE will be in effect,
subsequent CMS approvals of state requests for new or extended Appendix K
flexibilities will specify that the Appendix K flexibilities will terminate no later than six
months after the expiration of the PHE. Although formal public notice is not required,
states are strongly encouraged to keep 1915(c) waiver providers and participants up-to-
date on changes that will be ending and the date those changes will end.
Changes made through Appendix K that states would like to continue beyond the six-
month post-PHE timeline must be submitted as an amendment to the state’s 1915(c)
waiver application via the Waiver Management System (WMS). These amendments
must adhere to all policies and procedures detailed in the Version 3.6 1915(c) waiver
application and accompanying instructions, technical guide, and review criteria. 8
Examples of common changes in Appendix Ks that may be approved in a standard
1915(c) waiver application include the use of telehealth for certain services, addition of
home-delivered meals and other services, rate increases for waiver services, retainer
payments up to 30 days, and increased ability to pay family caregivers. Please be advised
that not all changes approvable through the Appendix K process may be included in the
standard 1915(c) waiver application, including, but not limited to, the extension of
timeframes for level of care re-evaluations, extensions of due dates for CMS-372s and
evidentiary reports, and waiving of certain settings and conflict of interest requirements.
In addition, changes approved using section 1135 waiver authority (e.g., extensions of
person-centered service plan recertifications, verbal signatures for person centered
service plans) generally may not be included as part of a standard 1915(c) waiver
application. States are encouraged to consult with CMS if they have questions about
what changes are permissible. Additional guidance on retaining temporary flexibilities is
available at: https://www.medicaid.gov/state-resource-center/downloads/allstatecall-
20200630.pdf.
8 The 1915(c) waiver application and accompanying technical guidance is available for download on the WMS website.
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III. Regulatory Requirements for Concluding Temporary Authorities
States will not need to take action to terminate temporary authorities that were approved with
specified sunset dates; however, states will need to comply with relevant regulatory provisions
when the transition back to regular operations results in, for example, terminations of coverage
or a reduction of benefits. Some of these regulatory requirements are related to redetermining
eligibility and assessing for coverage under another category or group prior to terminating
coverage, provision of advance notice and fair hearing rights, and reporting. States must comply
with these requirements when returning to regular operations after FFCRA provisions end, as
well as when ending temporary flexibilities adopted during the PHE. Appendix B provides a
snapshot of the regulatory requirements and the flexibilities subject to each requirement.
Conducting Renewals and Redeterminations
Once the PHE ends, states must take appropriate steps to redetermine eligibility and terminate
coverage, as appropriate, for individuals who remained enrolled due to the maintenance of
eligibility or continuous enrollment requirements in FFCRA, who gained or maintained coverage
during the PHE through a temporary change in eligibility requirements, or whose
redetermination was delayed due to circumstances described in 42 C.F.R. §435.912(e)(2),
§457.340(d), or §600.320(b). Under the continuous enrollment requirement in the FFCRA,
states seeking the temporary increase in FMAP under section 6008 of the FFCRA must treat
beneficiaries whose enrollment in Medicaid would be terminated but for compliance with section
6008(b)(3) of the FFCRA as eligible for benefits and keep them enrolled through the end of the
month in which the PHE ends.
As required at 42 C.F.R. §§435.916 and 457.343 (which generally incorporate the requirements
of §435.916 into CHIP), states must renew eligibility for Medicaid and CHIP beneficiaries
whose eligibility is determined using MAGI-based financial methodologies only once every 12
months. For Medicaid beneficiaries excepted from MAGI-based financial methodologies under
42 C.F.R. §435.603(j), states must renew such beneficiaries’ eligibility at least once every 12
months in accordance with §435.916(b). For BHP, states must redetermine eligibility every 12
months in accordance with 42 C.F.R. §600.340. In addition, as described at 42 C.F.R.
§435.916(d), §457.343, and §600.340(a), states must redetermine Medicaid, CHIP, and BHP
eligibility between regular renewals when they have information about a change in a
beneficiary’s circumstances that may affect eligibility.
In accordance with 42 C.F.R. §§435.916(a)(2) and (b) and 457.343, states must redetermine
eligibility without requiring information from the individual if able to do so based on reliable
information in the individual’s account or more current information available to the agency. If
the state is not able to redetermine eligibility because the available information does not establish
eligibility or is not recent or reliable, the state must request information from the beneficiary in
accordance with 42 C.F.R. §§435.916(a)(3) and (b) and 457.343. For BHP, states have the
option to follow the Medicaid redetermination policy described in 42 C.F.R. §435.916(a), or the
Exchange policy described in 45 C.F.R. §155.335.
In addition, verification regulations at 42 C.F.R. §435.952 and §457.380(d) (which incorporate
requirements of §435.952 into CHIP) require states to promptly evaluate information obtained or
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received by the agency and prevents states from denying or terminating eligibility or reducing
benefits on the basis of information received through electronic data sources unless the state
reached out to the beneficiary, provided a reasonable opportunity for the beneficiary to respond
and, as appropriate, provided advance notice and fair hearing (or in the case of CHIP, review)
rights. For BHP, states have the option to follow the Medicaid verification policy described in
42 C.F.R. §435.952 or the Exchange policy described in 45 C.F.R. §155.315 and §155.320.
For Medicaid beneficiaries who are found to no longer be eligible for the group in which the
individual receives coverage, states must consider all bases of eligibility prior to determining an
individual is ineligible for Medicaid in accordance with 42 C.F.R. §435.916(f)(1). States must
provide individuals determined ineligible for Medicaid on all bases with advance notice of
termination and fair hearing rights in accordance with 42 C.F.R. §435.917 and 42 C.F.R. Part
431, Subpart E. For CHIP, under 42 C.F.R. §457.350, states must screen for eligibility in
Medicaid and other insurance affordability programs prior to termination, and facilitate
enrollment in Medicaid if found potentially eligible. States must provide individuals determined
ineligible for CHIP timely notice of termination and review rights in accordance with 42 C.F.R.
§457.340(e) and 42 C.F.R. §457.1180. States may refer to the CMCS Informational Bulletin,
Medicaid and CHIP Renewal Requirements (Renewal CIB), which is available to assist states in
meeting their obligations to make accurate and timely redeterminations of eligibility and resolve
pending eligibility and enrollment actions. 9
States are expected to follow the regulatory requirements described above when completing
renewals and redeterminations after the end of the PHE. However, additional considerations
may apply in determining what actions are needed in particular circumstances.
• Redeterminations During the PHE for Individuals Continuously Enrolled: It is
important that states and territories receiving the temporary FMAP percentage point
increase under the FFCRA begin processing renewals and redeterminations based on
changes in circumstances during the PHE in accordance with 42 C.F.R. §435.916, to the
extent possible, if they are not currently doing so, even though they may not send the
final notice of termination or terminate coverage for beneficiaries who are found to no
longer be eligible for Medicaid. After the month in which the PHE ends, states and
territories will need to complete any outstanding renewals due during the PHE as well as
redetermine eligibility for changes in circumstances reported or identified during the
PHE. For states and territories that are able to complete some or all renewals and
redeterminations based on changes in circumstances during the PHE, a second
redetermination may need to be completed before a state may send advance notice and
terminate coverage when the FFCRA continuous enrollment requirement expires.
Section IV of this letter outlines the circumstances in which states may avoid repeating
redeterminations for beneficiaries whom the state could not terminate despite a finding
of ineligibility.
9 CMCS Informational Bulletin, Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements, available at
https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.
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• Redeterminations for Individuals Not Required to be Continuously Enrolled: States are
not required to provide continuous enrollment for individuals enrolled in a separate CHIP
or BHP during the PHE in order to comply with section 6008(b)(3) of the FFCRA, which
does not apply to these programs. It also is important that states process CHIP and BHP
renewals and redeterminations during the PHE in accordance with 42 C.F.R. §457.343
and §600.340 to the extent possible. As described in more detail below, some states have
the authority in their CHIP state plans or BHP Blueprints to use an exception in meeting
the timeliness standards for processing applications and redeterminations as a result of an
administrative or other emergency beyond the agency’s control. While the timeliness
exception for processing applications and redeterminations acknowledges that a state may
be unable to meet the time standards due to an emergency situation, this exception does
not alleviate states of the obligation to process applications and redeterminations if the
state is not prevented from doing so by the circumstances of the emergency or the
emergency no longer exists. It also does not provide authority to extend beneficiary
eligibility periods beyond what is necessary to use the exception.
• Redeterminations Based on Changes in State Eligibility and Enrollment Policies: Any
time a state imposes a more restrictive income methodology for an eligibility group or
ends coverage under an optional eligibility group, the agency must redetermine eligibility
for all affected beneficiaries. Some temporary flexibilities adopted by states, such as
adopting a less restrictive income methodology or establishing income and resource
disregards for MAGI-excepted eligibility groups in a Medicaid Disaster Relief SPA,
made some individuals temporarily eligible for Medicaid. Other temporary flexibilities,
like the adoption of continuous eligibility, allowed individuals to maintain eligibility even
if their circumstances changed. In addition, some states receiving the temporary FMAP
percentage increase paused efforts to impose more restrictive eligibility standards,
methodologies, or procedures in order to comply with the maintenance of effort
requirement under section 6008(b)(1) of the FFCRA. When temporary eligibility
changes and the maintenance of eligibility requirement sunset, agencies will need to
redetermine financial eligibility for beneficiaries who gained or maintained eligibility as
a result of these flexibilities or whose eligibility may be impacted with the adoption of a
more restrictive eligibility standard, methodology, or procedure. These beneficiaries are
considered to experience a change in circumstances that may affect eligibility when the
authority sunsets or more restrictive methodology is adopted, and the agency must
promptly act on such changes in accordance with 42 C.F.R. §435.916(d). The agency
must provide the beneficiary an opportunity to provide information or other
documentation to establish continued eligibility in accordance with 42 C.F.R.
§435.916(f)(1). 10 The agency must provide the beneficiary with a reasonable period of
time to provide such information or documentation in accordance with 42 C.F.R.
§435.952(c) and must enable the beneficiary to respond to the agency’s request online, by
phone, by mail, or in person. 11 CMS encourages states to establish a reasonable period of
time for all beneficiaries that is consistent with the requirement at 42 C.F.R.
10 Per 42 C.F.R. §435.916(d)(1)(i) and 42 C.F.R §457.343, for renewals of Medicaid and CHIP beneficiaries whose financial
eligibility is determined using MAGI-based financial methodologies, the agency must limit any requests for additional
information from the individual to information relating to the eligibility criterion impacted by the change in circumstances.
11 The required modes of submission are described at 42 C.F.R. §435.907(a).
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§435.916(a)(3)(i)(B) to provide MAGI beneficiaries at least 30 days to return information
at renewal. States may refer to Appendix A of the Renewal CIB for more information on
processing changes in circumstances. 12
• Transitions of Coverage Between Coverage Programs at the end of the PHE: Given that
we anticipate a significant increase in the number of individuals disenrolled from
Medicaid in states receiving the temporary FMAP percentage point increase once the
continuous enrollment and maintenance of eligibility requirements under the FFCRA
sunset, we also remind states and territories of their role in ensuring that individuals are
able to smoothly transition to other insurance affordability programs, such as CHIP or
enrollment in a Qualified Health Plan through the Marketplace, as appropriate, with
minimal disruptions. When an individual is determined ineligible for Medicaid on all
bases, states and territories must assess potential eligibility for other insurance
affordability programs and transfer the individual’s account in accordance with 42 C.F.R.
§435.916(f)(2). The account must include all of the information collected and generated
by the agency, regarding the individual’s Medicaid eligibility. 13 Similar requirements
exist in CHIP and BHP as outlined in 42 C.F.R. §457.350 and 42 C.F.R. §600.330(a),
respectively, when a beneficiary is determined no longer eligible for coverage under
those programs.
CMS understands that states may have a large volume of pending redeterminations that could not
be completed during the PHE. States and territories will need a reasonable period of time to
complete outstanding redeterminations and terminate coverage, as appropriate, when the PHE
ends, the FFCRA maintenance of eligibility and continuous enrollment requirements expire, and
any temporary eligibility authorities sunset. CMS outlines expectations related to completion of
this work in Section VI of this letter.
Providing Advance Notice to Beneficiaries
Whenever the Medicaid or CHIP agency makes a decision affecting a beneficiary’s eligibility or
when a beneficiary is subject to a termination, reduction or change in benefits and/or services or
an increase in beneficiary liability, the state generally must send a notice at least 10 days prior to
the date of action (defined at 42 C.F.R §431.201 as “the intended date on which a termination,
suspension, reduction, transfer or discharge becomes effective”) of the agency’s decision as well
as the beneficiary’s right to a Medicaid fair hearing as described at 42 C.F.R. §435.917 and 42
C.F.R. Part 431, Subpart E, or a CHIP review as described at 42 C.F.R. §457.340(e) and
§§457.1120-1190. 14 BHP enrollees are also entitled to notice of any decision concerning
eligibility as described in 42 C.F.R. §600.330(e) and must be provided notice of their appeals
right in accordance with §600.335(a). When a Disaster Relief SPA that temporarily expands
12 CMCS Informational Bulletin, Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements, available at
https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.
13 CMCS Informational Bulletin, Coordination of Eligibility and Enrollment between Medicaid, CHIP and the Federally
Facilitated Marketplace (FFM or “Marketplace”), available at https://www.medicaid.gov/sites/default/files/federal-policy-
guidance/downloads/cib072516.pdf.
14 As noted previously in this letter, states have flexibility to satisfy the requirement to determine eligibility on other bases prior
to terminating Medicaid eligibility and to provide fair hearing rights related to termination of coverage under the COVID-19
testing group.
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eligibility or provides additional benefits or services, such as creating a more flexible residency
policy or expanding monthly prescription limit, sunsets, the state also must provide beneficiaries
with advance notice of this change when the redetermination results in a decision of termination,
reduction, or suspension of eligibility, benefits, or services or an increase in beneficiary liability.
Similarly, when a section 1135 waiver sunsets and a level of care determination or functional
needs assessment is completed, the state must provide beneficiaries with advance notice of any
changes resulting from the determination or assessment. Additionally, when FFCRA section
6008(b) conditions no longer apply to a state, such as when section 6008(b)(4) of the FFCRA
expires at the end of the calendar quarter in which the PHE ends, states that complied with those
conditions in order to claim the temporary FMAP increase under section 6008 of the FFCRA
must provide beneficiaries advance notice of any eligibility, premium, coverage, or cost sharing
policies that are ending because the state is no longer subject to FFCRA section 6008(b), unless
the state chooses to extend these policies.
CMS recognizes that some states have been able to send notices during the PHE informing
Medicaid beneficiaries determined ineligible that their enrollment will end after the month in
which the PHE ends or, for other beneficiaries, as appropriate, that they will be subject to an
increase in cost sharing or other adverse action after the PHE ends. For such Medicaid
beneficiaries, states must send a second notice in advance of the adverse action, including
applicable fair hearing rights, at the end of the PHE in order to satisfy the due process
requirements codified in 42 C.F.R. Part 431, Subpart E. CMS outlines this obligation in more
detail in Section IV of this letter
Providing Fair Hearing Rights
Typically a state Medicaid, CHIP, or BHP agency must provide an individual the opportunity to
have a Medicaid fair hearing, CHIP review, or BHP appeal when an individual believes the state
has taken an action erroneously, including suspensions, terminations, or reductions of eligibility
or covered benefits or services, or when the state has denied the individual’s claim for eligibility
or for covered benefits or services (42 C.F.R. §431.220(a), §457.1120, §600.335). One
exception is that states are not required to provide a Medicaid fair hearing, CHIP review, or BHP
appeal when there is a change in law or policy, such as when the state makes a change to its state
plan to eliminate an optional benefit (42 C.F.R. §431.220(b), §457.1130(c), §600.335(b)). While
individuals would not be entitled to a fair hearing to appeal the end of eligibility or coverage of a
benefit or service that was authorized only during the PHE (e.g., the extension of eligibility to
non-residents temporarily residing in the state due to the PHE or addition of the personal care
benefit) (see 42 C.F.R. §431.220(b), §457.1130(c), §600.335), a beneficiary always has the right
to request a Medicaid fair hearing, CHIP review, or BHP appeal to contest that the decision was
wrong on another basis under existing authority. For example, if a beneficiary was terminated
for being over income once a temporary income disregard provided under a Medicaid Disaster
SPA ended, but the individual experienced a significant loss of income and this information was
not considered in the beneficiary’s redetermination, the beneficiary could request a fair hearing
based on the loss of income, if the individual believed he/she would be eligible for Medicaid.
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Completing Required Reporting
Some of the temporary authorities granted to states have associated reporting requirements that
need to be addressed. Other flexibilities affect existing reporting requirements, such as the
CMS-64, and will need to be accounted for in regular reporting.
Many states used the Appendix K process to extend deadlines for annual HCBS waiver CMS
372(S) reports. If the state specified a due date for the report(s) in its Appendix K, a CMS
analyst will contact the state 30 days prior to that date to offer an opportunity for the state to
provide updates to CMS regarding any changes to its submission date(s). If the state did not
specify a due date, a CMS analyst will follow-up at the conclusion of the PHE. CMS
acknowledges that 1915(c) quality reporting and cost estimates may be significantly affected by
the changes states made in their Appendix Ks or other authorities. For example, changes or
delays in provider qualifications allowed during the pandemic may adversely affect the state’s
performance on quality measures that assess whether providers continuously meet required
licensure or certification standards. Additionally, waiver cost estimates may be affected due to
temporary services, service limit increases, and rate increases. CMS is available for technical
assistance on how to address such issues.
Other reporting requirements include submission of annual upper payment limit (UPL)
demonstrations, as discussed in State Medicaid Director Letter 13-003. If applicable, these UPL
demonstrations would account for Medicaid state plan payment increases authorized by the
Disaster Relief SPAs. States can work with CMS on other adjustments that may be needed to the
UPL demonstrations as a result of the PHE.
IV. Other Requirements for Ending Specific Authorities
The COVID-19 outbreak affected states’ routine processes as they responded to the public health
crisis, and there are a number of instances where states modified their processes to adopt a
certain flexibility or used a temporary exception. Requirements for ending such specific
modifications are described below.
Terminating Coverage in the Optional Medicaid COVID-19 Testing Group
Authorization for the optional COVID-19 testing group established by the FFCRA expires at the
end of the PHE. States seeking the temporary FMAP increase under the FFCRA must maintain
enrollment for most beneficiaries enrolled as of or after March 18, 2020, through the end of the
month in which the PHE ends, unless the individual voluntarily disenrolls or is no longer a state
resident. 15 States may not claim federal financial participation (FFP) after the PHE ends for
services provided to individuals who remain enrolled in the COVID-19 testing group after the
PHE ends, however.
15 For additional information on the temporary FMAP increase and conditions for states and territories to qualify for it, see
section 6008 of the FFCRA, Interim Final Rule with Comment (IFC) CMS-9912-IFC, “Additional Policy and Regulatory
Revisions in Response to the COVID-19 Public Health Emergency, 85 FR 71142 (Nov. 6, 2020), and Medicaid and CHIP
Frequently Asked Questions, available at https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf
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Typically, in accordance with 42 C.F.R. §435.916(f), states must determine eligibility on all
bases prior to determining a beneficiary ineligible and provide advance notice at least 10 days
prior to termination and fair hearing rights, in accordance with 42 C.F.R. §435.917 and 42 C.F.R.
§§431.210 through 431.214. As described in the Operationalizing Implementation of the
Optional COVID-19 Testing (XXIII) Group: Potential State Flexibilities chart, available at
https://www.medicaid.gov/state-resource-center/downloads/potential-state-flexibilities-
guidance.pdf, and the COVID-19 Frequently Asked Questions document, available at
https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf, states have the
flexibility to satisfy the requirement to determine eligibility on other bases prior to terminating
Medicaid eligibility for beneficiaries enrolled in the COVID-19 testing group. States electing
this option would have provided notice at the time the initial eligibility notice is sent: (1) that
coverage through the COVID-19 testing group will be terminated at the end of the PHE; (2) that
the individual may be eligible for comprehensive Medicaid coverage; and (3) how to submit a
Medicaid application for comprehensive coverage. As part of the final termination notice, states
must again inform individuals who want to be considered for comprehensive coverage that they
must submit a Medicaid application for comprehensive coverage and how to do so, as well as the
circumstances when fair hearing rights would apply in accordance with 42 C.F.R.
§431.210(d)(2). (Please refer to Appendix B for more information on termination, notice and
redetermination).
Terminating Coverage for Individuals Determined Ineligible for Medicaid during the PHE
States receiving the temporary 6.2 percentage point FMAP increase under section 6008 of the
FFCRA may not disenroll most Medicaid beneficiaries for whom the state could not verify
eligibility or for whom the state could not determine that eligibility continues until the
continuous enrollment requirement under section 6008(b)(3) of the FFCRA and 42 C.F.R.
§433.400 expires. 16 There is the potential for a significant lapse in time to occur between when
the state or territory determined the individual was no longer eligible for Medicaid during the
PHE and when the state needs to send advance notice of termination, required under 42 C.F.R.
§431.211, prior to terminating coverage for that individual after the PHE ends. States and
territories receiving the temporary FMAP percentage point increase, as well as beneficiaries,
could face increased administrative burden if the state must, prior to sending such advance
notice, repeat post-enrollment verification procedures, redeterminations based on a change in
circumstances, or renewals for beneficiaries found ineligible during the PHE, including
beneficiaries whom the state determined no longer meet all eligibility requirements and
beneficiaries who did not respond to a request for information needed to determine their
eligibility.
States may avoid duplicative work associated with completing a second verification or
redetermination and limit duplicative beneficiary requests for information for beneficiaries
whom the state determined ineligible no more than 6 months prior to the date that the
beneficiary’s coverage is terminated. The process which states must follow to avoid having to
16 For additional information on the temporary FMAP increase and conditions for states and territories to qualify for it, see
section 6008 of the FFCRA, Interim Final Rule with Comment (IFC) CMS-9912-IFC, “Additional Policy and Regulatory
Revisions in Response to the COVID-19 Public Health Emergency, 85 FR 71142 (Nov. 6, 2020), and Medicaid and CHIP
Frequently Asked Questions, available at https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf
Page 15 – State Health Official
repeat post-enrollment verifications, redeterminations based on changes in circumstances, or
renewals in such cases depends on whether the state determined that the beneficiary does not
meet all eligibility requirements or the individual failed to respond to a request for information
needed to determine eligibility.
• Individuals determined ineligible: The following steps are required for states to avoid
repeating a renewal, redetermination, or verification for beneficiaries whom the state
determined ineligible within 6 months of the month in which the state sends advance notice
of termination following the end of the PHE. At the time of such determination of
ineligibility, states must inform such beneficiaries: 1) of the eligibility determination; 2)
their enrollment will end after the month in which the PHE ends; and 3) that they can and
should report any changes in circumstances while they remain enrolled and that the state
will redetermine their eligibility based on such changes. In addition, states and territories
must provide a second notice prior to the actual date of termination that meets the
requirements to provide a minimum 10-day advance notice of termination and fair hearing
rights in accordance with 42 C.F.R. Part 431, Subpart E.
• Individuals who fail to respond to a request for information: States must allow
beneficiaries to provide information or return necessary forms and/or documentation at
least through the end of the month in which the PHE ends, regardless of when the request
for information was sent. For beneficiaries who have not responded to a request for
information sent within 6 months of the actual termination date after the PHE ends, the
state does not need to attempt to repeat the verification or redetermination or to request the
needed information following the end of the PHE, but may instead provide the required
minimum 10-day advance notice of termination and fair hearing rights in accordance with
42 C.F.R. Part 431, Subpart E, prior to terminating coverage.
States must repeat any verification processes, redeterminations based on changes in
circumstances, and renewals for individuals whom the state determined ineligible, or from whom
the state had requested information needed to determine eligibility, more than 6 months prior to
the date of termination. This will ensure that the state takes final action based on reliable
information, consistent with 42 C.F.R. §435.916(a)(2) and (b).
Ending Temporary Verification Plan Changes
States must follow the verification policies and processes outlined in their MAGI-based
verification plan, along with MAGI and non-MAGI verification policies documented in the
state’s internal policies and procedures, consistent with federal statute and regulations. Some
states completed a Medicaid and CHIP Disaster Relief MAGI-Based Verification Plan
Addendum to establish temporary changes to their verification policies, such as the use of post-
enrollment verification. States that elected to enroll individuals based on self-attested
information and verify eligibility post-enrollment (post-enrollment verification) during the PHE
must access relevant data sources, consistent with their verification plan, and complete
verifications of eligibility for all beneficiaries enrolled within a reasonable timeframe and prior
to the beneficiary’s renewal, even if the state discontinues use of post-enrollment verification
after the PHE. In most cases, income will be the primary criterion of eligibility for states to
verify. As temporary verification policies and processes change (or sunset), including but not
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limited to the discontinuation of periodic data matching, states will need to have a plan in place
to reinstate these processes.
Ending Flexibilities Granted via Regulatory Concurrence
Federal regulations at 42 C.F.R. §435.912(e)(2), §457.340(d), §600.320(b), and 42 C.F.R.
§431.244(f)(4)(i)(B) provide states with an exception to meeting the timeliness standards for
processing applications and redeterminations under Medicaid, CHIP, and BHP, as well as
completing fair hearings and taking final administration action under 42 C.F.R. §431.244, caused
by an administrative or other emergency beyond the agency’s control. While the timeliness
exception for processing applications and redeterminations acknowledges that a state may be
unable to meet the time standards due to an emergency situation, this exception does not alleviate
states of the obligation to process applications and redeterminations if the state is not prevented
from doing so by the circumstances of the emergency or the emergency no longer exists. It also
does not provide authority to extend beneficiary eligibility periods beyond what is necessary to
use the exception.
Many states received an email providing CMS’ concurrence that the PHE did represent an
emergency triggering use of the timeliness exception in their Medicaid programs. Similar
acknowledgement for CHIP and BHP came in the form of an approval of a CHIP Disaster Relief
SPA or BHP Blueprint revision. These states should begin processing verifications,
redeterminations and renewals to the extent possible during the PHE and will need to ensure they
are able to comply with federal timeliness standards upon conclusion of the PHE.
• Timely Processing of Applications and Redeterminations: States that continue utilizing
the regulatory exception in meeting timeliness standards at 42 C.F.R. §435.912(e)(2),
§457.340(d), and §600.320(b) for processing applications, renewals, and changes in
circumstances due to workforce shortages, increased workloads and other disruptions to
their operations associated with the PHE must begin processing applications and
redeterminations timely when the PHE ends. We remind states that, in accordance with
42 C.F.R. §435.912(c) and §457.340(d), states are required to make determinations of
eligibility for MAGI and other non-disability applicants within 45 days. States must
make Medicaid determinations of eligibility on the basis of disability for applicants
within 90 days. 17 States must redetermine eligibility once every 12 months for MAGI
beneficiaries and at least once every 12 months for non-MAGI beneficiaries in
accordance with 42 C.F.R. §435.916 and §457.343, and must act promptly on changes
in circumstances consistent with 42 C.F.R. §435.916(d) and §457.343. Section VI of
this letter outlines expectations for states regarding the restoration of state eligibility and
enrollment operations when the PHE ends as well as for conducting eligibility and
enrollment processes to the extent possible during the PHE.
• Fair Hearing Timeframes: States utilizing the regulatory exception in meeting
timeliness standards at 42 C.F.R. §431.244(f)(4)(i)(B) to allow the state to take more
17 For more information on timely and accurate determinations of eligibility, see Medicaid and CHIP MAGI Application
Processing: Ensuring Timely and Accurate Determinations of Eligibility, available at https://www.medicaid.gov/state-resource-
center/downloads/mac-learning-collaboratives/timely-accurate-eligibility.pdf
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than 90 days to take final administrative action on fair hearing requests due to an
emergency beyond the state’s control must ensure they begin processing fair hearing
requests timely when the PHE ends. While some states may have been unable to hold
in-person fair hearings during the PHE, states may modify certain fair hearing processes
without need for additional state plan authority to avoid and reduce backlogs of fair
hearings. States may hold hearings by telephone or video, as long as the state is
providing access to the fair hearing process in accordance with 42 C.F.R. Part 431,
Subpart E (including providing access to individuals with disabilities and those who are
limited English proficient). Additionally, states may also resolve fair hearing requests
through informal resolution processes without additional state plan authority. CMS is
available to provide technical assistance to states related to fair hearing processes and
specifically regarding meeting the expected regulatory timeframes after the public health
emergency ends.
Ending Temporary 1915(c) Appendix K Flexibilities
Temporary changes approved in Appendix K submissions will automatically terminate when
they reach the end date indicated by the state in Section K-1-F of the Appendix K template. All
temporary changes must conclude and states must resume compliance with the language in their
current, approved 1915(c) waiver upon termination of the Appendix K. Any extensions of
waiver requirements included in the Appendix K must be concluded prior to the Appendix K’s
end date, with the exception of level of care recertification extensions. 18 For example, if a state
allows a 90-day extension for new providers to complete background checks, then only those
providers enrolled at least 90 days prior to the end date of the Appendix K would be eligible for
the full 90 day extension. A provider enrolled 60 days prior to the end date of the Appendix K
would only be eligible for a 60-day extension. If the state finds there is no longer need for any of
the provisions of the Appendix K, the state can elect to end the entire Appendix K by amending
the end date.
Ending Section 1135 Waivers
States received many different flexibilities through section 1135 waivers, which expire at the end
of the PHE. Each state will need to evaluate the 1135 waivers they received to determine the
types of actions that will be necessary as they sunset. Appendix C lists each 1135 waiver type
and the actions needed. Such actions may include:
• Informing Beneficiaries and Providers: States will need to inform affected providers and
beneficiaries when certain section 1135 waivers end. For example, states that received a
waiver of the HCBS settings rule will need to inform beneficiaries residing in these
settings that, pursuant to HCBS final regulation (CMS 2249-F/2296-F), they will be
moved to a location or setting that complies with the HCBS settings rule in order to
continue receiving Medicaid funding. States should work with impacted providers and
18 Many states extended level of care recertifications for 12 months beyond the due date of the recertification. In doing so, the
current level of care determination is considered valid for that individual for the entirety of the additional 12 month period, and
the recertification is not due until 12 months after the original due date, regardless of the end date of the Appendix K. Please note
that states cannot request extensions beyond 12 months for any given waiver participant.
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beneficiaries to ensure a smooth transition. Upon termination of the PHE, FFP for
services rendered at these facilities will no longer be available.
A number of states received flexibility under section 1135 waivers that allowed the
beneficiary’s representative to also furnish services to the beneficiary. As these types of
waivers sunset, states will need to inform beneficiary representatives that they may no
longer serve in the capacity of both a qualified provider and a representative or legally
responsible individual. In addition, states will need to inform beneficiaries of this change
and allow for choice of a new provider. For those states that received conflict of interest
waivers, they will need to work with providers that were temporarily authorized to
provide both case management and to render direct care HCBS to transition to providing
only one of these services. This waiver applies to provisions at 42 C.F.R.
§ 441.301(c)(1)(vi) for 1915(c) HCBS waivers, 42 C.F.R. § 441.555(c) for 1915(k)
Community First Choice, and 42 C.F.R. § 441.730(b) for 1915(i) State Plan HCBS.
• Revising Timeframes to Request a Fair Hearing: CMS granted states flexibility through
the end of the PHE, using section 1135 waiver authority, to allow applicants or
beneficiaries more than 90 days to request a fair hearing. 19 These extended time periods
for individuals to request fair hearings varied by state. Because individuals must be able
to rely upon the amount of time in the notice of adverse action they received, even after
the PHE ends, states need to honor these timeframes. However, for any new adverse
actions conducted after the PHE period ends, the state may either revert back to the state’s
fair hearing request timeframe prior to the section 1135 flexibility or may modify its
policy to provide an individual a longer reasonable time period (no longer than 90 days) to
request a fair hearing, in accordance with federal regulations. (42 C.F.R. §431.221(d)).
• Finalizing Provider Enrollments: Due to anticipation of workforce shortages, many states
utilized section 1135 waiver authority to delay revalidation of providers; to provisionally,
temporarily, enroll providers who are enrolled with another Medicaid agency or Medicare;
and/or to relax certain provider screening requirements for providers not already enrolled
with another Medicaid agency or Medicare, including, but not limited to, payment of an
application fee (42 C.F.R. §455.460) and fingerprint-based criminal background checks
(42 C.F.R. §455.434). These providers were required to meet a minimum set of
requirements, as reflected in the waiver approval language. Per the waiver approval, for
the temporarily provisionally enrolled providers, states have up to six months from the
end of the PHE (including any extensions) to cease payment to providers not fully
screened and enrolled. In addition, CMS will request an assurance from states that they
have taken the necessary steps to complete the screening of provisional enrollments.
For states that have temporarily paused revalidation work per their 1135 waiver approval,
revalidation work is expected to resume with the lift of the PHE. For those revalidation due
dates that occurred during the PHE, the state may delay the revalidation due date by the
amount of time the PHE is in place with an additional six months lead time to allow for
19 Section 42 C.F.R. §431.221(d) requires states to choose a reasonable timeframe for individuals to request a fair hearing, not to
exceed 90 days from the date the notice is mailed for eligibility or fee-for-service appeals.
Page 19 – State Health Official
notification to the provider of the new revalidation due date. The following example will
illustrate the timeline assuming the PHE, which began on March 1, 2020, was lifted on
November 1, 2020 (PHE in place for eight months). The provider’s revalidation due date
was March 2, 2020. Therefore, the state will move the provider’s revalidation due date to
May 2, 2021. In this example, the state has 14 months following the lift of the PHE to
notify and revalidate this provider. However, this amount of time will continue to increase
as long as the PHE remains in place. Also, for revalidations that are due within six months
after the expiration of the PHE, states will be granted an additional six months to complete
those revalidations.
• Completing Level of Care Assessments: Many states used section 1135 authority to delay
initial level of care (LOC) determinations for participants in 1915(c) waivers, 1915(k)
state plan programs, or initial functional needs assessments in 1915(i) and 1915(k) state
plan programs. However, CMS waiver approvals did not specify the time period for the
delay. CMS encourages states to complete these initial determinations via telehealth as
resources permit during the PHE. Upon the PHE conclusion, states should complete all
initial determinations delayed by the 1135 waiver within 90 days of the end of the PHE.
After the PHE has ended, states must adhere to the requirement that new participants have
their initial determinations completed prior to provision of any service.
Ending COVID-19 PHE Section 1115 Demonstrations
COVID-19 PHE Section 1115 demonstrations end no later than 60 days after the conclusion of
the PHE. States must submit a final report, consistent with the special terms and conditions of
the demonstration, one year after the demonstration ends. This report will consolidate all
required monitoring and evaluation deliverables for the demonstration. As the COVID-19 PHE
demonstrations contain authorities similar to the Disaster Relief SPAs and Appendix K
authorities, states should follow the guidance for restoring regular operations in the same manner
as recommended for the Disaster SPA and Appendix K authorities described earlier in this letter.
Requesting Formal Approval of Emergency IT Funding Requests
States can request emergency IT funding under 45 C.F.R. §95.624 whenever they face an
“emergency situation” as defined in regulations at 45 C.F.R. §95.605; this authority is not
aligned with the COVID-19 PHE. FFP approved under this authority is available from the date
the state acquires the IT equipment and services for which emergency funding was requested.
States with an approved emergency funding request must submit a formal request for approval
which includes the information specified in 45 C.F.R. §95.611 to CMS within 90 days of the date
of their requests for emergency IT funding. Additional information regarding this emergency IT
funding process can be found at 45 C.F.R. §95.624.
V. Operational and Managed Care Considerations
In addition to complying with relevant regulatory requirements when terminating temporary
authorities or changes made to comply with FFCRA provisions, states will need to take into
account other operational considerations when transitioning back to regular operations, some of
which are outlined below. Appendix D lists each temporary flexibility (eligibility and
Page 20 – State Health Official
enrollment flexibilities, SPAs, and waivers) and notes the operational considerations relevant to
each one.
Notifying Providers
Changes which were approved through a Disaster Relief SPA, such as temporarily lifting a
benefits limitation, allowing for a new covered service, or increasing provider payments, do not
have a specific provider notification requirement; however, states should rely upon their usual
processes for communicating such changes to the provider community. For example, depending
on how states posted the temporary rate increases during the PHE, states may need to use the
same means to inform providers of the payment rates that will be in effect upon the expiration of
the PHE.
Updating IT Systems and Internal Processes
As each of the flexibilities afforded to states during the PHE sunsets, these changes will need to
be reflected in the state’s internal IT systems and processes. States will need to communicate
policy changes internally to staff through updated materials and staff trainings and may need to
communicate new processes externally, such as through website changes. States will need to
make changes to their eligibility and enrollment systems to resume processes for terminating
coverage of ineligible individuals; changes to their mechanized claims processing and
information retrieval systems to remove coverage and payment for temporary services, and to
revert to payment rates prior to any temporary increases; and changes to their pharmacy system
to reinstate prior authorization requirements.
With respect to the COVID-19 testing group, states will need to take action to 1) disable or
remove the COVID-19 testing group from relevant systems – Eligibility and Enrollment (E&E),
Medicaid Management Information System (MMIS), Hospital Presumptive Eligibility (HPE),
family planning; 2) conclude 100% FFP for systems funding related to the COVID-19 testing
group; 3) establish claims edits for the COVID-19 testing group to prevent payment for services
that occur after the end of the PHE; and 4) remove access to the simplified application (if
applicable).
Ensuring Accurate Financial Reporting
States should ensure accurate and timely CMS-64 reporting of expenditures incurred during the
PHE period by following federal guidance, including FAQs on the claiming of FFCRA’s
increased FMAP and Medicaid Budget & Expenditure System (MBES) instructions on the new
optional COVID-19 uninsured testing group. Finally, for a state that implemented a temporary
interim payment methodology through the Disaster Relief SPA, the state must complete the steps
required by the SPA to reconcile interim payments to claims payment amounts; report any
reconciliations timely and accurately on the CMS-64; and, where applicable, return the federal
share of any overpayment to CMS.
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Considerations for Managed Care
As previously described in CMS guidance, if a benefit, or other identified flexibility, is covered
under a state plan, Medicaid waiver (such as section 1915(b) or 1915(c)), or a state
demonstration (such as section 1115), CMS has encouraged states to amend their managed care
contracts (if not already included in the contract) to extend the same flexibilities authorized
under their state plan, waiver, or demonstration to the same services when covered under the
managed care contract. While some states have chosen to align flexibilities with the contract
rating period (for example, telehealth options for services already covered under the managed
care contract), other states have chosen to extend flexibilities only for the duration of the PHE, to
align with their current Disaster Relief SPA or waiver approvals.
As states analyze which flexibilities to make permanent and which flexibilities to end with the
PHE, states should assess their managed care contracts to ensure consistency with their state
plan, Medicaid waiver, or demonstration. States must also notify their managed care plans as
needed of any changes that the state is considering using their usual processes for
communicating managed care plan changes. This will ensure that managed care plans have
adequate time to notify their network providers of any changes that affect the provider
community. We remind states that under 42 C.F.R. §§ 438.3(c)(1)(ii) and 438.4, final capitation
rates must be actuarially sound 20 and based only upon services covered under the state plan or
waiver authority, and must represent a payment amount adequate to allow the managed care
organization (MCO), prepaid inpatient health plan (PIHP), or prepaid ambulatory health plan
(PAHP) to efficiently deliver covered services to Medicaid-eligible individuals in a manner
compliant with contractual requirements.
Finally, some states have also considered adding permanent language to their managed care
contracts to describe non-payment flexibilities (such as modifying prior authorization
timeframes) and the terms under which such provisions of the contract would be invoked (such
as during a PHE). As long as a state has the appropriate Medicaid authority in place, and the
requirements in 42 C.F.R. Part 438 21 and the terms of their state plan, Medicaid waiver, or
demonstration are met, CMS encourages states to consider this approach as a possible strategy to
help mitigate administrative burden in future PHEs. We note that in some instances, this strategy
may require states to condition such contract terms on a future federal approval of a Medicaid
authority.
VI. Resuming Normal Eligibility and Enrollment Operations: Addressing Pending
Eligibility and Enrollment Actions
States are facing a number of challenges due to the ongoing PHE that will leave many states and
territories with large volumes of outstanding eligibility and enrollment actions when the PHE
ends. States have faced stay-at-home orders, social-distancing recommendations, and transitions
to telework, which impacted routine state operations. To accommodate workforce challenges
and an influx of applications, states were excused from complying with the usual timeliness
requirements for processing applications, changes in circumstances, and renewals, as permitted
20 For CHIP, under 42 C.F.R. § 457.1203 rates must be developed using actuarially sound principals.
21 For CHIP, under 42 C.F.R. Part 457 Subpart L.
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under 42 C.F.R. §435.912(e)(2), §457.340(d), and §600.320(b). In addition, states receiving the
temporary FMAP percentage increase may not terminate Medicaid coverage for most individuals
found to no longer meet eligibility requirements until the end of the month in which the PHE
ends. This will result in a backlog of cases, which may require a new redetermination and/or
advance notice and termination of coverage, as appropriate, at the end of the PHE.
CMS expects states to take steps during the PHE to prioritize actions that ensure eligible
individuals, particularly those with ongoing health care needs, are able to enroll and remain
enrolled in coverage. CMS also expects states to initiate verifications of all eligibility criteria for
individuals enrolled based on self-attested information, where additional verification is required
under regulations and the state’s verification plan (referred to as post-enrollment verifications in
this letter), renewals, and redeterminations based on changes in circumstances during the PHE.
States will need to address pending eligibility and enrollment actions after the month in which
the PHE ends in four key areas: processing applications received during the PHE, completing
verifications for individuals enrolled based on self-attested information during the PHE, as
applicable, acting on changes in circumstances experienced after a beneficiary’s last
determination, and completing renewals for beneficiaries whose eligibility period ended during
the PHE. We refer in this letter to application, verification, redetermination, and renewal actions
which are delayed due to the PHE together as COVID-related pending eligibility and enrollment
actions. States are expected to use a risk-based approach outlined in this letter to expeditiously
resume timely completion of all eligibility and enrollment actions.
CMS understands that states will not be able to immediately address the large number of pending
COVID-related eligibility actions that continue to accumulate during the PHE. Accordingly,
states may rely on the timeliness exception codified at 42 C.F.R. §435.912(e)(2), §457.340(d),
and §600.320(b), to excuse continued delay in resolving pending applications for up to four
months, and all other pending COVID-related eligibility and enrollment actions for up to six
months, following the end of the month in which the PHE ends. CMS will not request that states
document the use of the exception to meet these timelines in each case record as usually required
under 42 C.F.R. §435.912(f), §457.340(d), and §600.320(b), since states will need to develop
and document a plan to restore eligibility and enrollment operations. States do not need to
request concurrence or authority from CMS to use the timeliness exception and avoid
documenting the reason for delay in each beneficiary case record for purposes of complying with
the timelines outlined in this letter.
The timelines for states to complete COVID-related pending eligibility and enrollment actions
are described in more detail later in this section of this letter. The timelines provided, coupled
with the other flexibilities and strategies available to states to address pending actions, will
provide states a reasonable period to address the outstanding actions and resume timely
compliance with federal requirements. States that do not meet the timelines outlined in this letter
will be at increased audit risk and corrective action may be necessary.
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Planning for Post-COVID Eligibility and Enrollment Operations
Develop a Post-COVID Eligibility and Enrollment Operational Plan. In order for states to
achieve compliance within the timelines specified below after the end of the PHE, states will
need to develop and document a comprehensive plan, which we refer to in this letter as a “post-
COVID eligibility and enrollment operational plan.” To the extent a state has pending CHIP and
BHP cases when the PHE ends, states will need a post-COVID eligibility and enrollment
operational plan for CHIP and BHP or incorporate CHIP and BHP in their Medicaid planning
document. The post-COVID eligibility and enrollment operational plan is intended to help states
think through how they will achieve compliance and the steps necessary to operationalize the
plan.
States are expected to address in their plans how they will complete pending work delayed
during the PHE and simultaneously process current cases that require action within the timelines
specified in this letter. States will need to decide which flexibilities to retain (if permitted)
and/or whether to adopt new flexibilities to streamline eligibility and enrollment processes in
order to complete all pending COVID-related eligibility and enrollment actions within the
timelines specified below. States will also need to plan for necessary system changes to reverse
COVID-related flexibilities that expire at the end of the PHE.
CMS will release a Medicaid and Children’s Health Insurance Program COVID-related Pending
Eligibility and Enrollment Actions Resolution Planning Tool to assist states in their planning
efforts. The tool serves as an example of the types of issues states may need to address in their
planning efforts and also offers states the opportunity to address additional planning for other
areas where states may expect an influx of work after the PHE ends, such as preparing for an
increased workload of fair hearings. While CMS expects states to develop and document their
operational plan to address applications, verifications, changes in circumstances, and renewals,
states are not required to use the tool developed by CMS to document their plans and do not need
to submit their post-COVID eligibility and enrollment operational plans or the planning tool, if
used, to CMS for approval. States must make their plan available to CMS upon request or, as
needed, for audit purposes. States that are not on track to achieve compliance within the
timelines outlined in this letter should expect that CMS will request their post-COVID eligibility
and enrollment operational plan. CMS is available to provide technical assistance to states and
territories as they develop their plans.
Select a Risk-Based Approach to Address Pending Eligibility and Enrollment Actions. CMS
expects states to adopt a risk-based approach that prioritizes pending eligibility and enrollment
actions related to post-enrollment verifications, changes in circumstances, and renewals. A risk-
based approach prioritizes actions for individuals who are most likely to be no longer eligible for
coverage and minimizes the extent to which coverage is provided to individuals who no longer
meet eligibility criteria. Even if a case is prioritized in a risk-based plan, states must still process
all cases in accordance with 42 C.F.R. §435.916 and §435.940 through §435.960, including
ensuring that eligibility is determined on all bases prior to making a determination of
ineligibility. States and territories may select among four risk-based approaches to address the
backlog of pending cases and must clearly describe and document the risk-based approach in the
state’s post-COVID eligibility and enrollment operational plan.
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• Population-based approach: States and territories may adopt a population-based
approach that prioritizes completing outstanding eligibility and enrollment actions for
individuals in groups who are most likely to be no longer eligible.
Examples of populations CMS considers more likely to be no longer eligible when the
PHE ends, and which states and territories may wish to prioritize include:
o Individuals who became categorically ineligible for the group in which they are
enrolled during the PHE (e.g., individuals who, during the PHE, exceeded the
maximum age permitted for their eligibility group or individuals enrolled in the
adult group who became eligible for Medicare.);
o Individuals determined ineligible for Medicaid during the PHE, but not
terminated in order to comply with the continuous enrollment requirement under
the FFCRA in order to claim the temporary FMAP increase;
o Individuals who gained eligibility due to states’ use of a temporary eligibility
flexibility;
Populations whose eligibility tends to be stable, such as children, former foster youth, or
individuals dually eligible for Medicaid and Medicare, are not among the types of
populations CMS would expect states’ to prioritize in a population-based approach.
• Time-based approach: States may adopt a time-based approach that prioritizes cases
based on the length of time the action has been pending (age of action or aging reports),
such that the state completes oldest pending actions first.
• Hybrid approach: States may adopt an approach that combines the population and time-
based approaches. For example, a state may adopt a time-based approach prioritizing
outstanding post-enrollment verifications and changes in circumstances and a population-
based approach to prioritizing pending renewals. Alternatively, a state may adopt a
population-based approach for the first wave of pending actions processed following the
PHE and then switch to a time-based approach.
• State-developed approach: States may develop their own risk-based approach, which
prioritizes actions for individuals who are most likely to be no longer eligible or for
which there is a greater risk that ineligible individuals may remain enrolled longer.
States will need to clearly define a state-developed approach in the state’s post-COVID
eligibility and enrollment operational plan.
Consider additional flexibilities. CMS recognizes states with large volumes of pending COVID-
related eligibility and enrollment actions may want to consider in their planning efforts whether
to continue flexibilities adopted during the PHE, or adopt other eligibility and enrollment
strategies and flexibilities in order to meet the specified timelines. This may include strategies
discussed in sections II and VII of this letter to minimize state workloads or streamline eligibility
and enrollment processes for populations that tend to maintain eligibility for longer periods, such
as adopting Express Lane Eligibility or Continuous Eligibility for children, or utilizing renewal
processes required for MAGI beneficiaries for dually eligible beneficiaries. States also may need
to submit SPAs or revisions to their verification plan in order to continue flexibilities adopted
Page 25 – State Health Official
during the PHE or to adopt such new strategies and flexibilities, which also should be
documented in the state’s post-COVID planning document.
Create efficiencies by combining actions. States can create efficiencies by aligning work on
pending actions with an upcoming renewal and/or with a renewal or recertification conducted by
another benefit program, such as Supplemental Nutrition Assistance Program (SNAP), if such
renewal or recertification is due for completion in the 6-month timeframe. The following
describe potential efficiencies identified by CMS. States should indicate if they are using any of
these strategies in their post-COVID eligibility and enrollment operational plan.
• Aligning pending verification and change in circumstances with renewals: States may
wait to conduct pending post-enrollment verification and act on changes in circumstances
for beneficiaries whose renewal is due within 6 months after the month in which the PHE
ends.
This strategy cannot be used for beneficiaries whose next scheduled renewal is after this
6-month period, since that would result in unresolved pending COVID-related actions
beyond the maximum time provided. This strategy may not be applied to outstanding
verifications of citizenship or immigration status due to the statutory limit (90 days) on
the reasonable opportunity period provided to verify citizenship and immigration status.
• Aligning pending work with SNAP recertifications: For beneficiaries also enrolled in
SNAP, states with integrated eligibility systems may wait to act on a pending
verification, change in circumstances, or renewal until the individual’s SNAP
recertification is processed as long as the SNAP recertification is scheduled for
completion in time for the state to meet the maximum 6-month period to resolve all
pending COVID-related eligibility and enrollment actions. This strategy may not only
achieve greater efficiencies for stretched state resources, but can help states to align
renewal dates for Medicaid and SNAP.
This strategy cannot be used for beneficiaries whose next scheduled SNAP recertification
is after the 6-month period provided to resolve all pending COVID-related eligibility and
enrollment actions, nor may it be applied to outstanding verifications of citizenship or
immigration status.
Processing Pending Eligibility and Enrollment Actions During the PHE
States are expected to make every effort to make timely determinations of eligibility for new
applicants and to process changes in circumstances that may expand a beneficiary’s coverage
during the PHE. In order to meet the 6-month timeframe set forth in this letter for resolving all
other pending COVID-related eligibility and enrollment actions, it also will be critical for states
to begin processing pending post-enrollment verifications, changes in circumstances and overdue
renewals to the extent possible now, before the PHE ends. The following sets forth CMS’s
expectations for states in addressing pending eligibility and enrollment actions during the PHE.
• Applications: States are expected to process applications as expeditiously as possible
during the PHE, including disability-related applications or applications for other
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vulnerable populations. This is critical to ensure that coverage is available to eligible
individuals, particularly individuals with health conditions for whom delays in accessing
coverage could have long-term consequences. For more information on making timely
and accurate determinations of eligibility, states and territories may refer to the Medicaid
and CHIP MAGI Application Processing: Ensuring Timely and Accurate Determinations
of Eligibility resource. 22
• Verification of citizenship and immigration status: States must send appropriate notice
during the PHE to initiate a reasonable opportunity period for beneficiaries if the state
was unable promptly to verify attested citizenship or satisfactory immigration status with
the Social Security Agency or through the Systematic Alien Verification for Entitlements
(SAVE) Program operated by the U.S. Department of Homeland Security. The
reasonable opportunity period described at 42 C.F.R. §435.956(b), which must be
provided to applicants attesting to U.S. citizenship or satisfactory immigration status to
provide documentation of their status if electronic verification is not successful, does not
begin until such notice is received.
• Verifications based on available information: States are expected to resume checking
data sources to verify eligibility criteria for individuals enrolled based on self-attested
information during the PHE. This will enable states to complete post-enrollment
verification during the PHE for individuals whose attested information can be verified
with reliable data sources, thereby minimizing the state’s verification workload post-
PHE.
• Renewals based on available information: States also are expected to initiate Medicaid,
CHIP, and BHP renewals during the PHE based on electronic data and other information
available to the state. This will enable states to complete some renewals for eligible
individuals during the PHE and minimize renewal workload post-PHE.
CMS recognizes that it may not be feasible, due to the impact of the PHE on state operations, for
some states to request additional information from individuals whose attested information is not
verified by other data sources. CMS also recognizes that it may not always be efficient for states
to request additional information from Medicaid beneficiaries to determine continued eligibility
since states claiming the temporary FMAP increase may not terminate coverage for most
Medicaid beneficiaries through the end of the month when the PHE ends. However, CMS
encourages states to complete as many pending verifications, renewals, and redeterminations
based on changes in circumstances as possible during the PHE even if adverse action may not be
taken due to the protections afforded Medicaid beneficiaries under section 6008(b)(3) of the
FFCRA if the state is claiming the temporary FMAP increase. As discussed in section IV of this
letter, post-enrollment verifications, redeterminations following a change in circumstances, and
renewals that, but for the requirement to maintain enrollment per section 6008(b)(3) of the
FFCRA, would have resulted in termination (or other adverse action) and that are completed
within 6 months of a beneficiary’s actual termination date (or other adverse action) need not be
22 CMS, Medicaid and CHIP MAGI Application Processing: Ensuring Timely and Accurate Determinations of Eligibility,
available at https://www.medicaid.gov/state-resource-center/downloads/mac-learning-collaboratives/timely-accurate-
eligibility.pdf
Page 27 – State Health Official
repeated, provided that advance notice of termination and fair hearing rights are provided in
accordance with 42 C.F.R. part 431 subpart E.
We also note that states are not required to continue coverage during the PHE for enrollees in
separate CHIPs and BHP in order to claim the temporary FMAP increase, and therefore states
should complete pending verifications, redeterminations and renewals for enrollees in these
programs during the PHE to the extent possible. This includes accessing available information,
as well as sending pre-populated renewal forms to, or requesting other information from, CHIP
and BHP enrollees. Completing pending actions in these programs during the PHE will free up
resources for states to focus on pending Medicaid actions after the PHE ends.
Determining Eligibility Periods for Delayed Renewals
While states are expected to initiate and complete renewals based on available information
during the PHE, CMS understands that some states temporarily delayed all renewals or are not
able to complete renewals timely due to the impact of the PHE on state operations. In some
cases, states delayed certain renewals to prevent inappropriate terminations of coverage that
would have made the state ineligible to receive the temporary FMAP percentage increase. States
that resume the renewal process after an extended delay may be determining eligibility for a
large cohort of beneficiaries many months after the individual beneficiary’s originally-scheduled
renewal date. This has the potential to result in a large share of the state’s beneficiaries
scheduled for renewal in the same month in future years.
For beneficiaries scheduled for renewal during the PHE and whose eligibility is renewed without
requiring additional information from the individual consistent with 42 C.F.R §435.916(a) (i.e.
on an ex parte basis), states have the option to retain the beneficiary’s initial eligibility period
schedule, starting the day after the individual’s originally-scheduled renewal date rather than
based on the date that the state completes the redetermination and determines the individual to be
eligible. This option may assist states maintain a manageable renewal schedule in future years.
States should indicate in their post-COVID eligibility and enrollment operational plan how they
are establishing new eligibility periods for renewals due during the PHE that are delayed and
later resumed.
For example, a state that has delayed all renewals decides to resume the renewal process and
base new eligibility periods on the date of the originally-scheduled renewal. The state initiates
the renewal process on December 1, 2020, for a cohort of beneficiaries whose renewal was
originally due by April 30, 2020. For beneficiaries in this cohort who the state is able to renew
on an ex parte basis in December and are enrolled in a group whose eligibility is renewed once
every 12 months, the new eligibility period begins May 1, 2020, and extends through April 30,
2021. If the state in this example provides whole month coverage and had instead based new
eligibility periods on the date the renewal was completed, the new eligibility period would
instead begin on January 1, 2021.
This option only applies to beneficiaries for whom the state is able to renew eligibility without
requiring information from the individual. States do not have the option to determine when the
eligibility period may begin for beneficiaries for whom the state must request additional
information in order to complete the renewal. For renewals that require information from the
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individual, states must establish the new eligibility following the date of renewal to ensure the
renewal is based on reliable information and that requirements for the frequency of renewals are
met, consistent with §435.916.
For example, consider the process for resuming renewals for a state that suspended regular
processing of all renewals at the beginning of the PHE when that state ordinarily only terminates
coverage for beneficiaries at the end of a month. The state decides to resume processing of all
renewals during the PHE and initiates the renewal process on December 1, 2020, for a MAGI
beneficiary whose renewal was originally due by April 30, 2020. The state is unable to
determine continued eligibility based on the available information and sends the beneficiary a
pre-populated renewal form. The beneficiary returns the form on January 15, 2021, and the state
determines that the beneficiary remains eligible on January 29, 2021. The beneficiary’s new
eligibility period begins on February 1, 2021 and extends through January 31, 2022.
Timelines to Address Pending Eligibility and Enrollment Actions after the end of the PHE
The timelines set forth below reflect the amount of time that CMS has determined is reasonable
for states to resolve pending COVID-related eligibility and enrollment actions related to
applications, post-enrollment verifications, changes in circumstances, and renewals. To meet
these timelines, it will be critical for states to process pending eligibility and enrollment actions
in each of the focus areas described above to the extent possible during the PHE, and to have a
plan to expeditiously complete the pending actions that remain immediately after the month in
which the PHE ends and within the timeframes specified below.
• Applications – 2, 3, and 4 month milestones: Given that applications are received on a
rolling basis, CMS anticipates most states will have some pending applications at the end
of the PHE that were received during the PHE. While states should work as
expeditiously as possible to process applications during the PHE, agencies may use a
phased approach to complete eligibility determinations for pending applications received
during the PHE. CMS expects states to have caught up on any applications pending at
the end of the PHE and to have resumed making timely and accurate determinations of
eligibility on new applications no later than four months after the month in which the
PHE ends. CMS has established the following milestones to assist states in meeting this
timeline:
o 2 months: Complete eligibility determinations for all pending MAGI and other
non-disability related applications (e.g., individuals determined on the basis of
being aged) received during the PHE.
o 3 months: Complete eligibility determinations for all pending disability-related
applications received during the PHE. 23
o 4 months: Resume timely processing of all applications.
23 The Medicaid application processing time requirements at 42 C.F.R. §435.912(c) provide states and territories up to 90 days to
make determinations of eligibility for applicants who apply for Medicaid on the basis of disability and 45 days to make
determinations of eligibility for all other applicants. The milestones in this SHO letter are not intended to provide states and
territories with less time to make determinations of eligibility than what is allowed under federal regulation.
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CMS reminds states that an application is considered to be processed timely when the
agency enrolls an eligible applicant or denies coverage for an individual the agency
could not determine as eligible within the application time standards described at 42
C.F.R. §435.912(c) and §457.340(d).
CMS also reminds states of the requirement at 42 C.F.R. §435.912(g) and §457.340(d)
that agencies may not use the application timeliness standards – or the timelines
described in this letter – as a waiting period to delay determining eligibility or as a
reason for denying eligibility because the state has not determined eligibility within the
timeliness standards.
States are required to report performance indicator data, including application
processing times, which CMS has begun publicly releasing as part of Medicaid and
CHIP Scorecard 2.0. 24 CMS will use state application processing performance indicator
data submitted prior to the PHE as the baseline against which to measure states’ post-
PHE performance in order to determine when corrective action may be necessary for
states after the four month milestone is reached.
• Verifications, Changes in Circumstances, and Renewals – 6 months: As discussed, CMS
expects states to use a risk-based approach to prioritize pending eligibility actions related
to post-enrollment verification, changes in circumstances, and renewals. States are
expected to complete the COVID-related actions pending in these areas, including
termination of ineligible beneficiaries and those who do not provide requested
information needed to determine eligibility, as appropriate, no later than 6-months after
the month in which the PHE ends. In planning to meet this timeline, a few reminders are
important to note:
o Changes in Circumstances: Changes in circumstances experienced during the
PHE include any changes that may impact eligibility, including changes that were
anticipated or identified by the state, or reported to it. It also includes situations
in which a redetermination is needed due the expiration of temporary eligibility
flexibilities adopted by the state during the PHE (e.g., the expiration of an income
or resource disregard applied during the PHE).
o Renewals: CMS acknowledges that the need to process all renewals pending at
the end of the PHE within 6 months may lead to an uneven distribution of
renewals, concentrated in the months following the month in which the PHE ends,
which could impact timely processing of renewals in future years. CMS is
available to provide technical assistance to states and territories seeking to ensure
renewals are distributed evenly over the course of a year to ensure a manageable
and sustainable renewal workload in future years.
24 Medicaid and CHIP Scorecard 2.0, State Administrative Accountability, Medicaid and CHIP Application Processing Times,
available at https://www.medicaid.gov/state-overviews/scorecard/medicaid-magi-and-chip-application-processing-
times/index.html
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Monitoring State Progress and Corrective Action
CMS will monitor states’ progress in achieving the timelines described in this letter. Under the
authority in sections 1902(a)(6) and 1902(a)(75) of the Act and 42 C.F.R. §431.16, CMS will
require states to submit data demonstrating state progress in completing outstanding eligibility
and enrollment actions related to applications, verifications, changes in circumstances, and
renewals post-PHE. States and territories will be required to submit baseline data to CMS when
the PHE ends and to report data on a quarterly basis thereafter demonstrating state progress.
States that do not meet the timelines specified in this letter may be required to report data more
frequently. CMS will identify the data elements to be reported and provide a reporting template
for states to use.
States will continue to be required to report performance indicator data, including application
processing times, which CMS has begun publicly releasing as part of Medicaid and CHIP
Scorecard 2.0. 25 CMS will use state application processing performance indicator data submitted
prior to the PHE as the baseline against which to measure states’ post-PHE performance in order
to determine when corrective action may be necessary for states after four month milestone is
reached.
Audits, Eligibility Errors and Corrective Action Plans
CMS will not consider eligibility and enrollment actions delayed due to the PHE as untimely for
purposes of the Payment Error Rate Measurement (PERM) or Medicaid Eligibility Quality
Control (MEQC) programs if such actions are completed within the timelines detailed in this
letter. PERM and MEQC reviews will treat pending eligibility and enrollment actions that are
not completed timely as detailed in this letter as an eligibility error or technical deficiency.
Guidance on broader PERM and MEQC expectations will be provided separately to states. In
addition, states and territories that do not resolve their pending COVID-related eligibility and
enrollment actions within the timelines specified may be required to separately submit a
corrective action plan to CMCS outlining strategies and a timeline to come into compliance with
federal requirements.
VII. Strategies to Support Returning to Routine Operations
States may consider adopting a number of best practices and enrollment strategies to meet the
requirements outlined in this letter and restore regular operations efficiently.
Best Practices for Restoring Operations Upon Conclusion of the PHE
• Streamlining Notices - Combined Advance Notice of All Changes: Prior to terminating
many of the temporary changes enacted in response to the PHE, states must provide
Medicaid beneficiaries with at least 10 days advance notice, in accordance with 42 C.F.R.
§§431.206-214 and 435.917. States must provide CHIP enrollees with timely and
25 Medicaid and CHIP Scorecard 2.0, State Administrative Accountability, Medicaid and CHIP Application Processing Times,
available at https://www.medicaid.gov/state-overviews/scorecard/medicaid-magi-and-chip-application-processing-
times/index.html
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adequate written notice of any decision affecting eligibility in accordance with 42 C.F.R.
§457.340(e). BHP enrollees must be provided written notice of an eligibility
determination in accordance with 42 C.F.R. §600.330(e). These include any changes that
may result in ineligibility, along with the termination or reduction of services that were
temporarily added or increased during the public health emergency. States may issue a
combined notice describing all changes occurring at the close of the PHE, including
changes to eligibility, benefits, premiums and cost sharing. Such notice would also
provide information about the circumstances in which the individual may have a right to a
Medicaid fair hearing (42 C.F.R. §431.210(d)(2)), a CHIP review (42 C.F.R. §457.1180),
or a BHP appeal (42 C.F.R. §600.335).
• Ongoing Stakeholder Engagement: Although formal public notice is not required to end
the temporary changes elected in response to the PHE, states are strongly advised to
engage with providers, beneficiaries and their families, tribes and tribal organizations, and
other key stakeholders on an ongoing basis, to ensure they are well-informed of the
specific changes that will be ending and the date they will end. This is especially critical
for temporary services and service limit increases, provider qualifications, temporary rate
increases, and retainer payments that the state made available only for the duration of the
PHE. Methods states can use to keep their stakeholders informed of upcoming changes
include communications from case managers, mailings of hardcopy materials, email
blasts, and routine updates to Medicaid/CHIP Agency websites.
• Incorporation of COVID-Derived Program Modifications: States may wish to consider
evaluating the effect of any temporary changes made to the Medicaid program during the
PHE for promising practices that have fortified the state’s ability to provide services in
home and community-based settings. States are encouraged to submit 1915(c) waiver
amendments or SPAs to facilitate this. (See Section II for examples of modifications that
may be continued.)
Eligibility and Enrollment Strategies
States may wish to consider the adoption of one or more eligibility and enrollment strategies to
facilitate efficient restoration of Medicaid and CHIP operations upon conclusion of the PHE,
facilitate timely application and renewal processing, and assist states with staggering renewals to
ensure future caseloads are manageable. Some strategies states may consider include:
• Renewing Coverage When Processing Changes in Circumstances: For certain individuals
whom the agency determines continue to be eligible following a change in circumstances,
states may begin a new 12-month renewal period if the agency has information available
to it to verify eligibility with respect to all eligibility criteria without requiring any
additional information from the beneficiary in accordance with 42 C.F.R.
§§435.916(d)(1(ii) and 457.343. States may request, but not require, additional
information from the beneficiary about other factors needed to start a new renewal period
when the state is unable to verify all eligibility criteria based on information available to
the agency. States may refer to the Renewal CIB, for more information on renewing
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eligibility and processing changes in circumstances. 26 States do not need to submit a SPA
for CMS approval to implement this option.
• Facilitated Enrollment State Plan Option (with SNAP, Temporary Assistance for Needy
Families (TANF), or other programs): For some individuals receiving SNAP or other
means-tested benefits, such as TANF, states may use a targeted enrollment strategy to rely
on income determinations made by another program if the state is certain the individual
would be income-eligible using MAGI-based methods. This option can be used at
application, renewal, or both. States interested in this option may refer to the Policy
Options for Using SNAP to Determine Medicaid Eligibility State Health Official letter for
additional guidance. 27 To elect this option, states must submit a SPA.
• 12 Month Non-MAGI Renewals: States that renew eligibility more frequently than once
every 12 months for some or all of their non-MAGI beneficiaries may elect to renew
eligibility only once every 12-months (or another specified timeframe). Extending the
renewal timeframe may also simultaneously assist states address other state level priorities
such as increasing access to home and community based services by reducing the
frequency in which beneficiaries must respond to state requests. To elect this option,
states must submit a SPA.
• Adoption of MAGI Renewal Requirements for Non-MAGI Populations: Under 42 C.F.R.
§435.916(b) states may adopt renewal procedures required for MAGI beneficiaries under
42 C.F.R. §435.916(a)(3) for beneficiaries excepted from MAGI-based financial
methodologies. This includes using a pre-populated renewal form for beneficiaries whose
renewal cannot be completed using only information available to the state (sometimes
referred to as an ex parte or administrative renewal) and providing a minimum of 30 days
to respond. In addition, states may provide a reconsideration period for beneficiaries
whose eligibility was terminated at renewal for failure to return their renewal form or
other required information and who subsequently return their renewal form during the
reconsideration period without requiring the submission of a new full application. States
do not need to submit a SPA for CMS approval to implement these options.
• Reconsideration Period for Changes in Circumstances: States may offer a minimum 90-
day reconsideration period consistent with the reconsideration period provided for MAGI
beneficiaries at renewal under 42 C.F.R. §435.916(a)(3)(iii) and §457.343 for
beneficiaries whose eligibility has been terminated for failure to respond to a request for
information for a redetermination based on a change in circumstances, if the individual
subsequently returns the information. Offering a reconsideration period allows states to
determine an individual’s eligibility without requiring the individual to fill out a new
application to be determined eligible for benefits. The required information returned
26 CMCS Informational Bulletin, Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements, available at
https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.
27 State Health Official Letter, Policy Options for Using SNAP to determine Medicaid Eligibility and an Update on Targeted
Enrollment Strategies, available at https://www.medicaid.gov/federal-policy-guidance/downloads/SHO-15-001.pdf and CMCS
Informational Bulletin, Extended Use of the Targeted Enrollment “SNAP Strategy” under Section 1902(e)(14)(A) of the Social
Security Act, available at https://www.medicaid.gov/federal-policy-guidance/downloads/cib071917.pdf.
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within the reconsideration period serves as an application. This means that a
determination or denial of eligibility must be made consistent with timeliness standards in
42 C.F.R. §435.912 and §457.340(d), as applicable. States would also need to ensure they
collect any additional information from the individual that is not available to the state but
required at application, such as a signature. States may refer to the Renewal CIB for more
information on how to establish a new effective date of coverage and the provision of
retroactive eligibility for individuals who return information during a reconsideration
period and are determined eligible. 28 States do not need to submit a SPA for CMS
approval to implement this option.
States may also wish to consider the adoption of one or more eligibility and enrollment strategies
to streamline the enrollment and renewal process for populations that typically do not pose the
greatest risk to program integrity and are populations that states are likely to not prioritize in
their risk-based approach to restore eligibility and enrollment operations. Some population
specific strategies states may consider include:
• Streamlining Enrollment and Redeterminations for Children: There are approximately
35.9 million children enrolled in Medicaid and CHIP. States have additional options to
streamline the enrollment and redetermination process for children to promote continuity
of coverage for children and ease administrative burden on states.
o Express Lane Eligibility: Sections 1902(e)(13) and 2107(e)(1) of the Act permit
states to rely on findings from an entity designated by the state to determine whether
a child satisfies one or more factors of eligibility for Medicaid or CHIP. States may
use this authority at application, renewal, or both. States interested in this option
may refer to the CMS Express Lane Eligibility Option State Health Official letter for
additional guidance. 29 To elect this option, states must submit a SPA.
o Continuous Eligibility for Children: Under 42 C.F.R. §435.926 and §457.342, a
state may provide up to 12-months of continuous eligibility in Medicaid and CHIP
for children who are under age 19 or under a younger age specified by the agency.
This option provides the state with the authority to not act on changes in
circumstances for children (except turning 19, changes in state residency, death, or
voluntary termination, and for children enrolled in CHIP, becoming eligible for
Medicaid) during the continuous eligibility period. States implementing continuous
eligibility in Medicaid must apply the policy to all individuals in mandatory and
optional categorically needy groups under Section 1902(a)(10)(A) of the Act. To
elect this option, states must submit a SPA.
• Streamlining Application Processing and Renewals for Dually Eligible Beneficiaries:
There are approximately 12.2 million individuals enrolled in both Medicare and Medicaid,
and these individuals are less likely to experience significant fluctuations in income that
might lead to ineligibility at renewal. For this reason, states are encouraged to consider
implementing a number of approaches that could streamline the redetermination process
28 CMCS Informational Bulletin, Medicaid and Children’s Health Insurance Program (CHIP) Renewal Requirements.
29 State Health Official Letter, Express Lane Eligibility Option, available at https://www.medicaid.gov/sites/default/files/Federal-
Policy-Guidance/downloads/SHO10003.PDF
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for dually eligible beneficiaries and help states manage eligibility workload.
o Adoption of 12 Month Renewals: States that renew the eligibility of dually eligible
beneficiaries more frequently than once every 12-months may submit a SPA to
adopt a 12-month renewal cycle.
o Provision of Pre-Populated Renewal Forms and Reconsideration Period: States can
adopt certain streamlined renewal processes, which are required for MAGI-based
beneficiaries, for dually eligible beneficiaries without the need to submit a SPA or
seek approval from CMS. This includes use of a pre-populated renewal form for
beneficiaries whose renewal cannot be completed on an ex parte basis and the
provision of a 90 day reconsideration period for dually eligible beneficiaries
terminated for failure to return their renewal form or other required information
without the need for the individual to submit a new full application.
o Maximize Use of Ex Parte Renewal Process: States must attempt to conduct an ex
parte renewal for all beneficiaries as required at 42 C.F.R. §435.916(a)(2) and (b).
States can maximize use of the ex parte renewal processes by accepting information
in the case record which the state determines is highly unlikely to change for dually
eligible beneficiaries (such as income) as reliable information even if the state
requires documentation of income not verified electronically from other
beneficiaries. States do not need to submit a SPA or seek approval from CMS.
o Modify Verification Policies: States can accept self-attested information provided
on the renewal form for which documentation is not expressly required, consistent
with 42 C.F.R. §435.945, even if the state determines that documentation is needed
from other beneficiaries. States only need to update their internal non-MAGI
verification policy documents.
o Align MSP and LIS eligibility criteria: Low-income Medicare beneficiaries who
meet certain income and asset limits qualify for the Part D Low-Income Subsidy
(LIS), which provides assistance with Medicare Part D premiums and cost-sharing.
Many of these beneficiaries also qualify for Medicaid coverage of their Medicare
Parts A and B premiums and cost-sharing through the Medicare Savings Programs
(MSPs). The Social Security Administration (SSA) assesses LIS eligibility for
many applicants, and section 1144(c)(3) of the Act requires that SSA send LIS
application information to states for the purposes of initiating an MSP
application. Aligning MSP and LIS eligibility can help achieve substantial
efficiencies in the enrollment process, both for applicants and Medicaid agencies. If
a state uses the authority under section 1902(r)(2)(A) of the Act to align its MSP
income and/or asset eligibility criteria and definitions with those of the LIS program,
the state will have the option to consider LIS enrollees as meeting the eligibility
criteria for MSP. States that align the eligibility criteria can use LIS “leads data”
provided by the SSA to automate eligibility determinations without requiring a
separate MSP application. This strategy reduces burden on both the applicant and
the state by creating a streamlined process using the LIS “leads data” to enroll MSP
eligible individuals.
o Apply less restrictive income and/or resource criteria: States can effectively raise
the income and resources standards under the authority of section 1902(r)(2) of the
Act, which generally permits state Medicaid agencies to disregard income and/or
resources that are counted under non-MAGI financial eligibility methodologies.
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States may use the authority of section 1902(r)(2) of the Act to eliminate any income
or resource criteria for the MSP groups, thereby helping to streamline the
verification process. If a state agency chooses to adopt new less restrictive income
and resource methodologies, it must submit a SPA specifying the less restrictive
methodologies that will be used.
VIII. Program Integrity Considerations
Program integrity is one area for states to consider when developing plans to return to regular
operations when the PHE concludes. CMS will release guidance specific to COVID-19 program
integrity issues, including beneficiary eligibility, to assist states as they analyze which
flexibilities to seek to make permanent and which flexibilities to limit to cease after the duration
of the COVID-19 PHE ends. This program integrity guidance will outline expectations for states
to establish regular Medicaid program integrity operations post-PHE, taking into account new
changes to state programs as a result of implementing COVID-19 flexibilities, as described
above. Medicaid is a federal-state partnership, and collaboration is paramount to protecting the
integrity of state Medicaid programs. CMS is committed to working with states to ensure
adequate program integrity measures are in place post-PHE.
Closing
CMS remains committed to providing our state partners with the ongoing resources and technical
assistance necessary to respond effectively to the COVID-19 outbreak and restore state
operations upon the eventual conclusion of the current PHE. Please submit requests for technical
assistance to your CMS State Lead.
Sincerely,
Anne Marie Costello
Acting Deputy Administrator and Director
Cc:
National Association of Medicaid Directors
National Academy for State Health Policy
National Governors Association
American Public Human Services Association
Association of State and Territorial Health Officials
Council of State Governments
National Conference of State Legislatures
Academy Health
National Association of State Alcohol and Drug Abuse Directors
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APPENDIX A –Temporary Authorities Approved During the COVID-19 PHE
During a PHE or disaster, CMS can use various legal authorities to grant states’ emergency
flexibilities critical to ensuring a state’s ability to respond to the crisis expeditiously. Many of the
options and authorities available to states are described below.
Section 1135 Waivers
When the President declares a major disaster or an emergency under the Stafford Act or the
National Emergencies Act, and the HHS Secretary declares a PHE, the Secretary is authorized by
section 1135 of the Act to waive or modify certain requirements of titles XVIII, XIX, and XXI of
the Act, to the extent the Secretary determines necessary to ensure that sufficient health care
items and services are available to meet the needs of individuals enrolled in the respective
programs; and ensure that health care providers that furnish such items and services in good
faith, but are unable to comply with one or more of such requirements as a result of the
emergency, may be reimbursed and exempted from sanctions for noncompliance. To respond to
the COVID-19 outbreak, CMS has approved section 1135 waivers for all states and three
territories with respect to various Medicaid and CHIP-specific requirements, 30 in addition to the
Medicare-granted blanket 1135 waivers available to states and territories. 31 Examples of
flexibilities available include the ability to temporarily suspend prior authorization requirements,
provision of additional time for request for fair hearings and appeals, and relaxation of rules to
enable faster enrollment of providers.
Section 1915(c) Appendix K Template
Appendix K is a stand-alone appendix of the 1915(c) HCBS Waiver Instructions and Technical
Guidance that states may complete in emergency situations to accelerate amendment requests for
approved 1915(c) HCBS waivers. It specifies actions that states can take under the existing
section 1915(c) HCBS waiver authority in order to respond to an emergency. 32 Changes made
through Appendix K are time-limited, tied specifically to individuals affected by the emergency,
and may be applied retroactively by the state. Public notice requirements normally applicable
under section 1915(c) waivers do not apply to amendments made through Appendix K because
the changes are temporary and will not affect the Appendix K’s underlying 1915(c) waiver when
they end. Flexibilities available include addition of an electronic method of service delivery for
certain services, allowing for service continuity without face-to-face interaction, addition of
services to address additional needs of waiver recipients during the emergency, permitting
retainer payments if the disaster necessitates the absence of an individual from a regularly
scheduled program or service, allowing family members to serve as service providers,
30 During the COVID-19 outbreak, CMS pre-packaged relevant and commonly requested 1135 waivers into a checklist template
to expedite states’ ability to apply for and receive approval of the waivers. The checklist is available at
https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/cms-1135-waivers/index.html.
31 Information on Medicare-granted blanket 1135 waivers is available at: https://www.cms.gov/about-cms/emergency-
preparedness-response-operations/current-emergencies/coronavirus-waivers.
32 To support the specific types of flexibilities that states requested during the COVID-19 outbreak, CMS designed an Appendix
K template addendum pre-populated with commonly requested and relevant program changes. The appendix is available at
https://www.medicaid.gov/state-resource-center/disaster-response-toolkit/hcbs/appendix-k/index.html.
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temporarily adjusting rates to respond to the disaster, and temporary adjustments to process
requirements to reduce administrative expectations until the end date specified in the Appendix
K.
Medicaid Disaster Relief SPA Template
The Medicaid state plan is the document that describes the state’s rules related to eligibility,
benefits, payments and other key operational aspects of how states administer their Medicaid
program. States have wide discretion within a broad federal framework to design their programs,
and changes are processed through SPAs. During a disaster or emergency situation, states may
wish to make temporary changes. To streamline and support this process, CMS developed a
Medicaid Disaster Relief SPA template specific to the COVID-19 PHE that allows a state to
submit one combined request for temporary changes states may wish to make in their
programs. 33 The template addresses expanding temporary coverage to optional eligibility
groups, adding specialized benefits, expanding access to Medicaid services furnished via
telehealth by removing limitations that states may have in their program, and temporarily
increasing or enhancing provider payment, among other temporary changes.
CHIP Disaster Relief SPAs
Similar to Medicaid, the CHIP state plan describes how the state administers its program and
changes to the plan are processed through SPAs. States can submit CHIP SPAs that allow for
temporary adjustments to beneficiary enrollment and eligibility redetermination policies during
disaster events. The purpose is to implement provisions for temporary adjustments to enrollment
and redetermination policies and cost sharing requirements for children in families living and/or
working in Governor- or federally-declared disaster or emergency areas. The CHIP Disaster
Relief SPA may be submitted in advance of, or in response to, a disaster or public health crisis. 34
BHP Blueprints
The BHP Blueprint is a comprehensive written document submitted by the state to the Secretary
for certification of a BHP. On May 8, 2020, 35 CMS issued an interim final rule with comment
period (85 FR 27550, 27593) that included a policy permitting states operating BHPs to submit
revised BHP Blueprints for temporary changes to their BHPs that could be effective retroactive
to the first day the COVID-19 PHE. 36 States can use this flexibility during the COVID-19 PHE
to implement temporary modifications and temporary significant changes that are directly tied to
the COVID-19 PHE and would increase enrollee access to coverage.
33 The Medicaid Disaster Relief SPA template is available at: https://www.medicaid.gov/state-resource-center/disaster-response-
toolkit/state-plan-flexibilities/index.html.
34 The CHIP Disaster Relief SPA is available at https://www.medicaid.gov/resources-for-states/disaster-response-toolkit/state-
plan-flexibilities/index.html
35 85 Fed. Reg. 27550, 27593, May 8, 2020, available at https://www.federalregister.gov/documents/2020/05/08/2020-
09608/medicare-and-medicaid-programs-basic-health-program-and-exchanges-additional-policy-and-regulatory.
36 See the Medicare and Medicaid Programs, Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions
in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing
Facility Quality Reporting Program Interim Final Rule (85 FR 27550).
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Medicaid and CHIP Disaster Relief MAGI-Based Verification Plan Addendum
States have discretion in establishing Medicaid and CHIP eligibility verification policies to
implement federal requirements 37 and must develop and update a verification plan describing the
state’s income and eligibility verification policies and procedures. 38 States must submit their
Medicaid and CHIP MAGI-based verification plans to CMS and must document any changes to
non-MAGI verification practices in the state’s internal policies and procedures. To streamline
and support this process during an emergency, CMS developed a Medicaid and CHIP Disaster
Relief MAGI-Based Verification Plan Addendum to allow states to submit temporary changes to
state verification policies and procedures to CMS. 39 Such temporary changes may include
suspending periodic data matches or electing to enroll individuals, where permissible, based on
self-attested information and verify eligibility post-enrollment (post-enrollment verification).
Section 1115 Demonstration Opportunity
On March 22, 2020, CMS released State Medicaid Director Letter (SMDL) #20-002 outlining a
new section 1115(a) demonstration opportunity to aid states with addressing the PHE. 40 The
SMDL includes an application template that allows states to select waiver and expenditure
authorities to streamline demonstration application requirements. With this template, states are
able to request CMS approval of certain waivers as well as certain expenditure authorities to
streamline enrollment into long-term care programs and provide access to HCBS for
beneficiaries, as well as vary and target services based on population needs. States may request
other flexibilities to deliver the most effective care to their beneficiaries in response to the
COVID-19 PHE. Due to the extraordinary circumstances of this emergency, pursuant to 42
C.F.R. §431.416(g), CMS determined an exception to the normal state and federal public notice
procedures is warranted and the Department is not requiring states to submit budget neutrality
calculations. States are still required to track expenditures for approved demonstrations through
standard CMS-64 reporting processes.
Emergency IT Funding
HHS will provide FFP at the applicable rates for state expenditures on automated data processing
systems, including Medicaid mechanized claims processing and information retrieval systems, in
certain circumstances during emergency situations, if the state submits a request pursuant to 45
C.F.R. §95.624. This authority is not limited to the period of the COVID-19 PHE declaration.
To obtain emergency IT funding under this authority, states submit a request for FFP prior to the
acquisition of any equipment or services. The request must be reflected in a record, and must
include: a brief description of the equipment and/or services to be acquired as well as an estimate
of their costs, a brief description of the circumstances driving the state’s need to proceed prior to
obtaining approval from the agency through the usual regulatory process, and a description of the
harm that will be caused if the state does not immediately acquire the requested equipment
37 Set forth in requirements at 42 C.F.R. §435.940 through §435.956 and 42 C.F.R. §457.380.
38 In accordance with requirements at 42 C.F.R. §435.945(j) and §457.380(j).
39 https://www.medicaid.gov/medicaid/eligibility/downloads/magi-based-verification-plan-addendum-template.docx
40 Information on the COVID-19 section 1115 demonstration opportunity is available at:
https://www.medicaid.gov/medicaid/section-1115-demonstrations/1115-application-process/index.html.
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and/or services. This process is more streamlined than the advance planning document (APD)
process by which states typically request funding approval.
For example, states could submit emergency IT funding requests to obtain FFP in their
expenditures to expand the state’s ability to support automated data processing systems via a
remote work force (e.g., via telework), including to acquire state-owned laptops and other
hardware and software. Emergency IT funding requests can also be submitted for IT
infrastructure enhancements necessary to support the state’s plan related to the COVID-19 PHE
declaration, including claims processing, eligibility determinations, reporting, analytics, data
collection, and applied research.
Within 14 days of receiving the state’s emergency IT funding request, CMS will either approve
or disapprove it. If CMS approves the request, the state must submit a formal request for
approval through the usual APD process within 90 days of the date of the state’s emergency IT
funding request. If the state fails to submit a formal request for funding to CMS within 90 days
of its emergency request, then the emergency IT funding will be disapproved retroactive to the
date of the initial emergency request. Pursuant to 45 C.F.R. 95.623, a state may request
reconsideration of disapproved IT funding, including if funding is disapproved because the state
did not submit its formal funding request by the 90-day deadline, or if the state exercised a
related contract without having received CMS prior approval. The usual APD approval process
will govern CMS’s formal approval of scope, timeline, and funding.
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APPENDIX B – Requirements for Ending Temporary Flexibilities
States must comply with certain regulatory requirements when they end temporary flexibilities
and when they transition back to regular operations at the end of the PHE. They will need to
take appropriate steps to redetermine eligibility and terminate coverage, as appropriate, for
individuals who remained enrolled due to the continuous enrollment requirement in FFCRA, or
who gained or maintained coverage during the PHE through a temporary change in eligibility
requirements. Similarly, when the state makes a decision affecting a beneficiary’s eligibility or
when ending an authority results in a termination, reduction or change in benefits or services, the
state must generally provide at least 10-days advance notice of the change and the beneficiary’s
right to a Medicaid fair hearing or a CHIP review. Fair hearing rights are not triggered when
temporary flexibilities end at the conclusion of the PHE, so they are not listed in the table, but
individuals still have the right to a fair hearing if the agency’s decision was made incorrectly, for
example, because the individual’s circumstances have changed.
The following tables list the temporary flexibilities related to the continuous enrollment
requirement in section 6008(b)(3) of the FFCRA, as well as Medicaid and CHIP Disaster Relief
SPAs and section 1135 waivers. For each flexibility, the tables indicate whether termination of
that flexibility requires the state to redetermine eligibility in accordance with 42 C.F.R. §435.916
and §457.343 or to provide advance notice in accordance with 42 C.F.R. Part 431, Subpart E,
and §§ 435.917, 457.340(e) and 457.1120-1190. The redetermination and notice columns are
selected in the tables below only when the termination of a flexibility itself creates the need for a
redetermination or advance notice. They are not selected when some event subsequent to and
resulting from termination of the flexibility might require a redetermination or advance notice.
In some cases, a redetermination or advance notice may follow or result from the termination of
a flexibility, but not result directly from the termination of the flexibility itself. For example,
states do not need to notify beneficiaries when a section 1135 waiver modifying the deadline for
initial level of care determinations for 1915(c) waivers ends. However, the state may need to
redetermine eligibility and provide advance notice when an initial level of care determination is
completed after the waiver ends.
Regulatory Requirements for Ending Temporary Flexibilities
Table B-1: Continuous Enrollment Requirement Under Section 6008(b)(3) of FFCRA
(for states seeking the temporary FMAP increase)
Provide Advance
Action – Redetermine
Notice to
Terminations at the end of the PHE for: Eligibility
Beneficiaries
Beneficiaries enrolled based on self-attested information,
X
for whom the state has not completed verification
Beneficiaries whose renewals were delayed and a
X X
redetermination of eligibility has not been initiated
Beneficiaries who experienced a change in
X X
circumstances that the state did not act upon
Beneficiaries who received a determination of
ineligibility during the PHE and remained enrolled under X
6008(b)(3) of the FFCRA
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Table B-2: Temporary SPA Authorities
Provide Advance
Redetermine
Action Notice to
Eligibility
Beneficiaries
Eligibility
Election of the COVID-19 testing group X1 X
Adoption or modification of less restrictive
X X
methodologies
More flexible residency policies X X
Extension of the reasonable opportunity period
Enrollment
Changes to presumptive eligibility (PE) or hospital
presumptive eligibility (HPE)2
Extension of the renewal period for non-MAGI
populations
Adoption or modification of continuous eligibility
X3 X
for children
Premiums and Cost Sharing
Suspension of cost sharing X
Suspension of premiums X
Benefits
Addition or expansion of benefits X
Adoption of more flexible limitations or loosening of
X
amount, duration, and scope
Addition or expansion of benefits in Alternative Benefit
X
Plans
Revised utilization of telehealth
Pharmacy
Changes to day/quantity supply (e.g., amount of
medication dispensed at one time) for covered
outpatient drugs
Changes to monthly prescription limit (e.g., number of
X
prescriptions allowed per month.)
Changes to prior authorization requirements for
medications on automatic renewal
Changes to preferred drug list
Adjustment of professional dispensing fees
Changes to coverage of investigational drugs X
Payment
Payment for additional benefits
Increased payment rates
Establishment of supplemental payments or interim
payment methodology
Post Eligibility Treatment of Income (PETI)
Modification or variance of the basic personal needs
X
allowance for institutionalized individuals
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Provide Advance
Redetermine
Action Notice to
Eligibility
Beneficiaries
CHIP-Specific Provisions
Waiver of the waiting period
Waiver of the premium lock-out period
Suspension of premiums and cost sharing X
Table B-3: Section 1135 Waiver Authorities
Provide Advance
Redetermine
Action Notice to
Eligibility
Beneficiaries
Authorizations
Temporary suspension of fee-for-service prior
authorization requirements
Extension of pre-existing fee-for-service prior
X4
authorizations
30-day delay of Pre-Admission Screening and Annual
Resident Review (PASRR) Level I and Level II
assessments
Managed Care
Extension of timelines for the provision of authorized
X4
services and for service authorization decisions
Extension of timelines for appeal requirements
Fair Hearings
Extension of timelines for state fair hearing requests and
appeals
Extension of the timeframe for the reinstatement of
services and benefits for an individual who files a fair
hearing request after the date of action
Provider Enrollment & Participation
Waiver of certain provider enrollment requirements
Waiver of provider conditions to allow for provision of
services in alternative settings
Home and Community-Based Services
Modification of the deadline for initial level of care
determinations for 1915(k) state plan benefits and
1915(c) HCBS waivers
Modification of the deadline for level of care
redeterminations for 1915(k) state plan benefits and
1915(c) HCBS waivers
Modification of the deadline for initial evaluations of
eligibility and assessments of functional needs for
1915(i) state plan benefits
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Provide Advance
Redetermine
Action Notice to
Eligibility
Beneficiaries
Modification of the deadline for re-evaluations of
eligibility and reassessments of functional needs for
1915(i) state plan benefits
Modifications of the deadline for initial assessments of
functional need for 1915(k) state plan benefits
Modification of the deadline for re- reassessments of
functional needs and person-centered service plan for
1915(k) state plan benefits
Modification of the deadline for conducting the
assessments to make a determination that an individual
requires 1915(j) self-directed Personal Assistance
Services and supports and for the development of the
service plan and budget. These activities do not need to
be completed before the start of care.
Modification of the deadline for annual review of the
service plan required for the 1915(j) state plan benefit.
The review can be postponed up for up to one year.
Allowing legally responsible individuals to render
X
personal care services
Temporary provision of HCBS in specified settings that
X
have not been determined to meet HCBS settings criteria
Temporary provision of HCBS by entities also providing
case management services under a temporary waiver of X
conflict of interest requirements
Waiver of the requirement to obtain beneficiary and
provider written consent of new or amended HCBS
person-centered service plans
Modification of the deadline for a face-to-face encounter
for 1905(a)(7) home health state plan services
Allowing an individual’s representative to render 1915(j)
X
and/or 1915(k) services
Private Duty Nursing
Allowing Private Duty Nursing (PDN) services to be
delivered by a graduate registered nurse and/or graduate X
licensed practical nurse
Allowing PDN services to be directed by a nurse
practitioner, clinical nurse specialist, and/or physician
assistant
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Provide Advance
Redetermine
Action Notice to
Eligibility
Beneficiaries
Clinic Facility Requirement
Permitting the state and clinic to temporarily designate a
clinic practitioner’s location as part of the clinic facility
so that clinic services may be provided via telehealth
when neither the patient nor practitioner is physically
onsite at the clinic
Provision of clinic services within scope without the
direction of a physician or dentist
Psychiatric Services
Provision of inpatient psychiatric services within scope
for individuals under age 21 without the direction of a
physician
Targeted Case Management
Modification of the deadline for conducting annual
monitoring and follow-up activities for targeted case
management
1
The steps states may take to redetermine eligibility and terminate coverage as appropriate under the COVID-19
testing group may be different than other groups. See Section IV of this letter for additional detail.
2
Regulations at §435.1101 define the beginning and end dates for PE coverage, which begins on the day that the
qualified hospital or other entity approves PE, and ends the earlier of the last day of the month after the PE
determination, or if a full application is filed by then, the date full Medicaid eligibility is determined. In states that
temporarily added new eligibility groups to hospital PE or expanded the MAGI-based eligibility groups covered in
PE, at the end of the PHE, there will be individuals who have been determined presumptively eligible for a group
covered in a disaster SPA, but who do not yet have a full Medicaid eligibility determination. With the exception of
individuals determined presumptively eligible for the COVID-19 testing group, states should continue to provide PE
until the end of the PE period consistent with the requirements at 42 C.F.R. §435.1101. Individuals determined
presumptively eligible for the COVID-19 testing group should receive a notice of termination effective at the end of
the month in which the PHE ends.
3
States must begin acting on changes in circumstances for children once the PHE ends and must redetermine
eligibility for children with reported changes during the PHE.
4
Beneficiaries whose receipt of services is discontinued pending a new authorization must be provided with
advance notice.
Page 45 – State Health Official
Appendix C – Timeframes for Resolution of Section 1135 Waivers and Pending Eligibility and Enrollment Actions
As states end the temporary flexibilities authorized by section 1135 waivers and transition back to regular operations at the end of the PHE,
they will need to complete certain required actions. Some actions must occur immediately at the conclusion of the PHE, or earlier if the
flexibility expires prior to the end of the PHE. For example, a state that received a section 1135 waiver to temporarily suspend fee-for-service
prior authorization requirements, would need to lift that suspension and reinstate the prior authorization requirements immediately at the
conclusion of the PHE. For other flexibilities, CMS will use enforcement discretion to give states a reasonable period of time following the
end of the PHE, in which to complete the action. For example a state that utilized the flexibility regarding timely processing of new
applications will be expected to resume timely processing of all applications within 6 months of the conclusion of the PHE.
Table C-1 lists the actions necessary to resolve pending determinations of eligibility and enrollment. Table C-2 then lists each section 1135
waiver, along with the action required to end that waiver. For each action listed – related to both eligibility and enrollment and section 1135
waivers – the table specifies the time period within which the action is expected to be completed.
Maximum Timeframes for Completing Required Actions
Table C-1: Acting on Pending Eligibility and Enrollment Actions
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Verification
Complete post-enrollment verification X
Application Processing
Complete processing of MAGI and non-disability-related X
applications received during the PHE
Complete processing of disability-based applications
X
received during the PHE
Resume timely processing of all applications X
Page 46 – State Health Official
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Changes in Circumstances
Complete changes in circumstances reported, identified,
or anticipated during the PHE and resume promptly X
acting on all changes in circumstances
Renewals
Complete any outstanding renewals and resume timely
X
processing of all renewals
Table C-2: Actions to End Section 1135 Waivers
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Authorizations
Temporary suspension of fee-for-service prior
authorization requirements X
– Lift the suspension
Extension of pre-existing fee-for-service authorizations
X
– End the extension
30-day delay of Pre-Admission Screening and Annual
Resident Review (PASRR) Level I and Level II
X
assessments
– Restore standard practices
Page 47 – State Health Official
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Managed Care Service Authorizations and Appeals
Extension of timelines for service authorization and
appeal requirements for Medicaid managed care X
– Stop providing extensions
Fair Hearings
Extension of timelines for state fair hearing requests
X
– Stop providing extensions
Extension of the timeframe for the reinstatement of
services and benefits for an individual who files a fair
X
hearing request after the date of action
– Stop providing extensions
Provider Enrollment & Participation
Waiver of certain provider enrollment requirements
– Require completion of enrollment requirements
– Complete revalidation of providers (the state may
delay the revalidation due date by the amount of X
time the PHE is in place with an additional six
months lead time to allow for notification to the
provider of the new revalidation due date)
Waiver of provider conditions allowing for provision of
services in alternative settings X
– Discontinue
Home and Community-Based Services
Modification of the deadline for initial level of care
determinations for 1915(k) state plan benefits and
1915(c) HCBS waivers X
– Complete initial level of care determinations
Page 48 – State Health Official
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Modification of the deadline for level of care
redeterminations for 1915(k) state plan benefits and
X3
1915(c) HCBS waivers
– Complete level of care redeterminations
Modification of the deadline for initial evaluations of
eligibility and assessments of functional needs for
X
1915(i) state plan benefits
– Complete initial evaluations and assessments
Modification of the deadline for re-evaluations of
eligibility and reassessments of functional needs for
X3
1915(i) state plan benefits
– Complete re-evaluations and reassessments
Modifications of the deadline for initial assessments of
functional need for 1915(k) state plan benefits X
– Complete initial assessments
Modification of the deadline for re- reassessments
of functional needs and person-centered service X3
plan for 1915(k) state plan benefits
– Complete re-evaluations and service plans
Modification of the deadline for conducting the
initial assessments to make a determination that an
individual requires 1915(j) self-directed Personal X
Assistance Services and Supports and for the
development of the service plan and budget.
– Complete initial assessment and service plan
Modification of the deadline for annual review of the
service plan required for the 1915(j) state plan benefit. X3
– Complete re-evaluations
Page 49 – State Health Official
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Allowing legally responsible individuals to render
personal care services X
– Discontinue
Temporary provision of HCBS in specified settings that
have not been determined to meet HCBS settings criteria X
– Discontinue
Temporary provision of HCBS by entities also providing
case management services under a temporary waiver of
X
conflict of interest requirements
– Lift the waiver
Waiver of the requirement to obtain beneficiary and
provider written consent of new or amended HCBS
X
person-centered service plan
– Lift the waiver
Modification of the deadline for a face-to-face encounter
for 1905(a)(7) home health state plan services X3
– Complete face-to-face encounter
Allowing an individual’s representative to render 1915(j)
and/or 1915(k) services X
– Discontinue
Private Duty Nursing
Allowing Private Duty Nursing (PDN) services to be
delivered by a graduate registered nurse and/or graduate
X
licensed practical nurse
– Discontinue
Allowing PDN services to be directed by a nurse
practitioner, clinical nurse specialist, and/or physician
assistant X
– Discontinue
Page 50 – State Health Official
At Within 90
Within 2 Within 4 Within 6 Within 12
conclusion days / 3
months of months of months of months of
Action of PHE or months of
PHE PHE PHE PHE
end of PHE
conclusion conclusion conclusion conclusion
authority1 conclusion
Clinic Facility Requirement
Permitting the state and clinic to temporarily designate
a clinic practitioner’s location as part of the clinic
facility so that clinic services may be provided via
X
telehealth when neither the patient nor practitioner is
physically onsite at the clinic
– Discontinue
Provision of clinic services within scope without the
direction of a physician or dentist X
– Discontinue
Psychiatric Services
Provision of inpatient psychiatric services within scope
for individuals under age 21 without the direction of
X
a physician
– Discontinue
Targeted Case Management
Modification of the deadline for conducting annual
monitoring and follow-up activities for targeted case
management X3
– Complete annual monitoring and follow-up
1
A section 1135 waiver must be discontinued prior to the end of the PHE, or an earlier end date specified in the waiver, if it is no longer necessary to meet the purposes
of section 1135(a) of the Social Security Act.
3
Complete within 12 months of the due date.
Page 51 – State Health Official
Appendix D - Operational Actions Needed to End Temporary Authorities
In addition to complying with relevant regulatory requirements when terminating temporary
authorities or changes made to comply with FFCRA provisions, states will also need to consider
other operational implications as they transition back to regular operations. The tables below list
each temporary flexibility (eligibility and enrollment flexibilities related to the FFCRA and
regulatory concurrences, Disaster Relief SPA authorities, and section 1135 waivers) and note the
operational considerations relevant to that flexibility. For example, as a state ends the temporary
suspension of cost sharing authorized through a Medicaid or CHIP disaster SPA, the state will
need to inform providers that they must begin collecting copays again, update their systems to
require the collection of copays, reduce provider payments and state claiming by applicable cost
sharing, and determine whether any revisions to their managed care contracts are needed to
reinstate this policy.
Operational Activities to Consider as Temporary Authorities End
Table D-1: Acting on Pending Eligibility and Enrollment Actions
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Continued coverage of ineligible
beneficiaries who remained enrolled under X X X
6008(b)(3) of the FFCRA
Exception to timely application processing X
Exception to promptly acting on changes in
X
circumstances
Exception to timely completion of renewals X
Temporary use of post-enrollment
verification X
Table D-2: Ending SPA Authorities
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Eligibility
Election of the COVID-19 testing group X X X X
Adoption or modification of less
X X X
restrictive methodologies
More flexible residency policies X X X
Extension of the reasonable
opportunity period X X X
Page 52 – State Health Official
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Enrollment
Changes to presumptive eligibility (PE) or
X X X
hospital presumptive eligibility (HPE)
Extension of the renewal period for non-
X
MAGI populations
Adoption or modification of continuous
X
eligibility for children
Premiums and Cost Sharing
Suspension of cost sharing X X X X
Suspension of premiums X X x
Benefits
Addition or expansion of benefits X X X X
Adoption of more flexible limitations or
X X X X
loosening of amount, duration, and scope
Addition or expansion of benefits in
X X X X
Alternative Benefit Plans
Revised utilization of telehealth X X X X
Pharmacy
Changes to day/quantity supply (e.g.,
amount of medication dispensed at one X X X X
time) for covered outpatient drugs
Changes to monthly prescription limit
(e.g., number of prescriptions allowed X X X X
per month.)
Changes to prior authorization
requirements for medications on X X X X
automatic renewal
Changes to preferred drug list X X X X
Adjustment of professional
X X X X
dispensing fees
Changes to coverage of investigational
X X X X
drugs
Payment
Payment for additional benefits X X X X
Increased payment rates X X X X
Establishment of supplemental payments
or interim payment methodology X X X X 41
41 In the context of Medicaid managed care, states should assess any managed care implications from the establishment of new
state directed payments under 42 C.F.R. § 438.6(c) specifically related to the PHE. See our published guidance regarding this
topic at: https://www.medicaid.gov/federal-policy-guidance/downloads/cib051420.pdf and https://www.medicaid.gov/federal-
policy-guidance/downloads/cib082420.pdf.
Page 53 – State Health Official
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Post Eligibility Treatment of Income
Modification or variance of the basic
personal needs allowance for X X X X
institutionalized individuals
CHIP-Specific Provisions
Waiver of the waiting period X X
Waiver of the premium lock-out period X X
Suspension of premiums and cost sharing X X X X
Table D-3: Ending Section 1135 Waiver Authorities
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Authorizations
Temporary suspension of fee-for-service
X X X
prior authorization requirements
Extension of pre-existing fee-for-
X X X
service prior authorizations
Temporary suspension of Pre-Admission
Screening and Annual Resident Review X X X X
(PASRR) Level I and Level II assessments
Managed Care Service Authorizations and
X
Appeals
Extension of timelines for service
authorization and appeal requirements for X X X X
Medicaid managed care
Fair Hearings
Extension of timelines for state fair
X X X
hearing requests
Extension of the timeframe for the
reinstatement of services and benefits for
X X
an individual who files a fair hearing
request after the date of action
Provider Enrollment & Participation
Waiver of certain provider enrollment
X X X X
requirements
Waiver of provider conditions to allow for
provision of services in alternative settings X X X X
Page 54 – State Health Official
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Home and Community-Based Services
Modification of the deadline for initial
level of care determinations for 1915(k)
X X X X
state plan benefits and 1915(c) HCBS
waivers
Modification of the deadline for level of
care redeterminations for 1915(k) state X X X X
plan benefits and 1915(c) HCBS waivers
Modification of the deadline for initial
evaluations of eligibility and assessments
X X X X
of functional needs for 1915(i) state plan
benefits
Modification of the deadline for re-
evaluations of eligibility and
X X X X
reassessments of functional needs for
1915(i) state plan benefits
Modifications of the deadline for initial
assessments of functional need for 1915(k) X X X X
state plan benefits
Modification of the deadline for re-
reassessments of functional needs and
X X X X
person-centered service plan for 1915(k)
state plan benefits
Modification of the deadline for
conducting the initial assessments to
make a determination that an individual
requires 1915(j) self-directed Personal X X X X
Assistance Services and Supports and for
the development of the service plan
and budget.
Modification of the deadline for annual
review of the service plan required for the X X X X
1915(j) state plan benefit.
Allowing legally responsible individuals
X X X X
to render personal care services
Temporary provision of HCBS in
specified settings that have not been X X X X
determined to meet HCBS settings criteria
Temporary provision of HCBS by entities
also providing case management services
X X X X
under a temporary waiver of conflict of
interest requirements
Waiver of the requirement to obtain
beneficiary and provider written consent
of new or amended HCBS person-centered X X X X
service plans
Page 55 – State Health Official
Update Ensure Assess
Inform Systems Accurate Managed
Action
Providers and/or Financial Care
Processes Reporting Implications
Modification of the deadline for a face-to-
face encounter for 1905(a)(7) home health X X X X
state plan services
Allowing an individual’s representative to
X X X X
render 1915(j) and/or 1915(k) services
Private Duty Nursing
Allowing Private Duty Nursing (PDN)
services to be delivered by a graduate
X X X X
registered nurse and/or graduate licensed
practical nurse
Allowing PDN services to be directed by a
nurse practitioner, clinical nurse specialist, X X X X
and/or physician assistant
Clinic Facility Requirement
Permitting the state and clinic to
temporarily designate a clinic
practitioner’s location as part of the clinic
facility so that clinic services may be X X X X
provided via telehealth when neither the
patient nor practitioner is physically onsite
at the clinic
Provision of clinic services within
scope without the direction of a X X X X
physician or dentist
Psychiatric Services
Provision of inpatient psychiatric services
within scope for individuals under age 21 X X X X
without the direction of a physician
Targeted Case Management
Modification of the deadline for
conducting annual monitoring and follow- X X X X
up activities for targeted case management
Page 56 – State Health Official
Appendix E – State Eligibility and Enrollment Pending Action Timelines for Resolution
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