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, 
Childrens 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 Childrens 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 states 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 
nations 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 CMSs 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.   Page 3  State Health Official 
 
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 SPAs7 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 states 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 Courts 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.   Page 7  State Health Official 
 
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 states 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.   Page 8  State Health Official 
 
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 
beneficiarys 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 individuals 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  Page 9  State Health Official 
 
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 Childrens Health Insurance Program (CHIP) Renewal Requirements, available at 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib120420.pdf.   Page 10  State Health Official 
 
  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 agencys 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 agencys 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).  Page 11  State Health Official 
 
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 individuals 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 individuals 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 beneficiarys 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 agencys decision as well 
as the beneficiarys 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 Childrens 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.  Page 12  State Health Official 
 
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 individuals 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 beneficiarys 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.   Page 13  State Health Official 
 
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 states 
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  Page 14  State Health Official 
 
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 
beneficiarys 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 
states 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 beneficiarys 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  Page 16  State Health Official 
 
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 agencys 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  Page 17  State Health Official 
 
than 90 days to take final administrative action on fair hearing requests due to an 
emergency beyond the states 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 Ks 
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.  Page 18  State Health Official 
 
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 
beneficiarys 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 states 
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 providers revalidation due date 
was March 2, 2020. Therefore, the state will move the providers 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 states 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 FFCRAs 
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.  Page 21  State Health Official 
 
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 sound20 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 43821 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.   Page 22  State Health Official 
 
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 states 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 beneficiarys 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.   Page 23  State Health Official 
 
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 Childrens 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 
states post-COVID eligibility and enrollment operational plan.  Page 24  State Health Official 
 
  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: 
  Individuals who became categorically ineligible for the group in which they are 
o
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.); 
  Individuals determined ineligible for Medicaid during the PHE, but not 
o
terminated in order to comply with the continuous enrollment requirement under 
the FFCRA in order to claim the temporary FMAP increase; 
  Individuals who gained eligibility due to states use of a temporary eligibility 
o
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 states 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 states 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 individuals 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 beneficiarys 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 CMSs 
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  Page 26  State Health Official 
 
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 states 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 beneficiarys 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 beneficiarys originally-scheduled 
renewal date.  This has the potential to result in a large share of the states 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 beneficiarys initial eligibility period 
schedule, starting  the day after the  individuals 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  Page 28  State Health Official 
 
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 beneficiarys 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: 
  2 months: Complete eligibility determinations for all pending MAGI and other 
o
non-disability related applications (e.g., individuals determined on the basis of 
being aged) received during the PHE. 
  3 months: Complete eligibility determinations for all pending disability-related 
o
applications received during the PHE.23
  4 months:  Resume timely processing of all applications.  
o
 
 
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.  Page 29  State Health Official 
 
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: 
  Changes in Circumstances: Changes in circumstances experienced during the 
o
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). 
  Renewals: CMS acknowledges that the need to process all renewals pending at 
o
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  Page 30  State Health Official 
 
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  Page 31  State Health Official 
 
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 states 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  Page 32  State Health Official 
 
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 individuals 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 Childrens 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.    Page 33  State Health Official 
 
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.   
  Express Lane Eligibility:  Sections 1902(e)(13) and 2107(e)(1) of the Act permit 
o
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. 
  Continuous Eligibility for Children:  Under 42 C.F.R. 435.926 and 457.342, a 
o
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 Childrens 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   Page 34  State Health Official 
 
for dually eligible beneficiaries and help states manage eligibility workload.   
  Adoption of 12 Month Renewals:  States that renew the eligibility of dually eligible 
o
beneficiaries more frequently than once every 12-months may submit a SPA to 
adopt a 12-month renewal cycle.   
  Provision of Pre-Populated Renewal Forms and Reconsideration Period:  States can 
o
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. 
  Maximize Use of Ex Parte Renewal Process: States must attempt to conduct an ex 
o
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. 
  Modify Verification Policies:  States can accept self-attested information provided 
o
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. 
  Align MSP and LIS eligibility criteria:  Low-income Medicare beneficiaries who 
o
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.    
  Apply less restrictive income and/or resource criteria:  States can effectively raise 
o
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.   Page 35  State Health Official 
 
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  Page 36  State Health Official 
 
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 states 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 Ks 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.  Page 37  State Health Official 
 
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 states 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).  Page 38  State Health Official 
 
Medicaid and CHIP Disaster Relief MAGI-Based Verification Plan Addendum 
States have discretion in establishing Medicaid and CHIP eligibility verification policies to 
implement federal requirements37 and must develop and update a verification plan describing the 
states 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 states 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 states 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.  Page 39  State Health Official 
 
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 states 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 states 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 states 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 states 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 CMSs formal approval of scope, timeline, and funding.    Page 40  State Health Official 
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 beneficiarys 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 beneficiarys 
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 agencys decision was made incorrectly, for 
example, because the individuals 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  Page 41  State Health Official 
 
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  Page 42  State Health Official 
 
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  Page 43  State Health Official 
 
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 individuals 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  Page 44  State Health Official 
 
Provide Advance 
Redetermine 
Action  Notice to 
Eligibility 
Beneficiaries 
Clinic Facility Requirement     
Permitting the state and clinic to temporarily designate a 
clinic practitioners 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 
  X       
1915(c) HCBS waivers  
  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 individuals 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 
X         
assistant 
  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 practitioners 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 
        X3
management  
  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 
  X     
verification 
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  
  X  X  X 
opportunity period  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 
X  X  X  X41 
or interim payment methodology 
 
 
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 
X  X  X  X 
provision of services in alternative settings  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 
X  X  X  X 
of new or amended HCBS person-centered 
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 individuals 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 
practitioners 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