DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services  
7500 Security Boulevard, Mailstop S2-26-12  
Baltimore, Maryland 21244-1850
 
                SHO# 21-006 
 
RE: Mandatory Medicaid and 
CHIP Coverage of COVID-19-
Related Treatment under the 
American Rescue Plan Act of 2021 
 
 
October 22, 2021 
 
Dear State Health Official:  
 
The Centers for Medicare & Medicaid Services (CMS) is issuing this guidance on Medicaid and 
Childrens Health Insurance Program (CHIP) coverage of COVID-19-related treatment under the 
American Rescue Plan Act of 2021 (ARP) (Pub. L. No. 117-2, enacted on March 11, 2021).  As 
discussed below, the ARP requires state Medicaid and CHIP programs1 to cover COVID-19-
related treatments, without cost-sharing.  CMS will apply the statutory interpretations in this 
guidance on a prospective basis beginning with the date of issuance of this letter. 
 
ARP Sections 9811 and 9821 
 
Section 9811(a) of the ARP added a new mandatory Medicaid benefit at section 1905(a)(4)(F) of 
the Social Security Act (Act).  Section 9821 of the ARP added the same mandatory benefit for all 
CHIP enrollees at section 2103(c)(11)(B) of the Act.  Under these amendments, beginning March 
11, 2021, state Medicaid programs and separate CHIPs2 are required to cover treatments for 
COVID-19, including specialized equipment and therapies (including preventive therapies).  
Additionally, under these amendments, beginning March 11, 2021, state Medicaid programs and 
separate CHIPs must cover the treatment of a condition that may seriously complicate the 
treatment of COVID19, if otherwise covered under the state plan (or waiver of such plan, 
including a section 1115 demonstration) for individuals who are diagnosed with or presumed to 
have COVID-19 during the period such an individual has (or is presumed to have) COVID19.3  
Section 9811(a)(2) of the ARP amended the statutory language following section 1902(a)(10)(G) 
of the Act to require coverage of the same COVID-19-related treatment for individuals eligible 
for the Medicaid optional COVID-19 group (formerly referred to by CMS as the optional 
COVID-19 testing group) described at section 1902(a)(10)(A)(ii)(XXIII) of the Act.4  
                                                           
1 Use of the term state in this letter includes the territories, as applicable.  
2 Section 2103(c)(11)(B) applies to child health assistance and pregnancy-related assistance provided through a 
separate CHIP. Section 1905(a)(4)(F) of the Act applies to Medicaid expansion CHIP funded by title XXI.  
3 Under section 1905(a)(4)(F) of the Act, this coverage of treatment for complicating conditions in Medicaid should 
be provided without regard to the Medicaid comparability requirements of section 1902(a)(10)(B) of the Act. 
4 Under section 1905(b) of the Act, state expenditures on medical assistance for this optional COVID-19 group, and 
state expenditures described in section 1903(a)(7) of the Act that a state demonstrates to the satisfaction of the 
 
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 
 
 
ARP sections 9811 and 9821 also amended sections 1916, 1916A, and 2103(e)(2) of the Act to 
specify that states cannot impose cost sharing with respect to the COVID-19-related treatment 
coverage that is required under the ARP and described at sections 1905(a)(4)(F) and 
2103(c)(11)(B) of the Act.  ARP section 9811(a)(5) also amended section 1937(b) of the Act to 
require states to include the same COVID-19-related treatment coverage in Medicaid alternative 
benefit plans, without any deduction, cost sharing, or similar charge. 
   
These coverage requirements and cost-sharing prohibitions generally end on the last day of the 
first calendar quarter that begins one year after the last day of the COVID-19 emergency period 
described in section 1135(g)(1)(B) of the Act.  However, under section 1902(a)(10)(A)(ii)(XXIII) 
of the Act and the statutory language following section 1902(a)(10)(G) of the Act, states can 
provide Medicaid coverage to the optional COVID-19 group only through the last day of the 
COVID-19 public health emergency (PHE).  No federal financial participation is available for any 
state expenditures on benefits for this group, including coverage of COVID-19-related treatments, 
after the PHE ends.  
  
Below, we discuss the requirements in ARP sections 9811 and 9821 to cover treatment 
specifically for COVID-19 (including preventive therapies), and then discuss the requirements 
to cover treatments for a condition that may seriously complicate the treatment of COVID-19.  
We also discuss the cost-sharing prohibition with respect to these items and services (including 
drugs), as well as state plan considerations for implementing these provisions of the ARP.  
 
Treatment for COVID-19, Including Specialized Equipment and Therapies, and Preventive 
Therapies  
 
Sections 9811 and 9821 of the ARP require states to cover treatments specifically for COVID-
19, including specialized equipment and therapies, and preventive therapies.  This requirement is 
very broad and encompasses a wide array of possible treatments and therapies, both 
pharmacological and non-pharmacological, as further explained below.  CMS interprets this 
coverage to also include coverage for treatments and therapies for post-COVID conditions, 
sometimes called long COVID.  Long COVID includes a range of symptoms that can last 
weeks or months after a person is first infected with the virus that causes COVID-19 or that can 
appear weeks after infection.5  
  
With respect to non-pharmacological items and services, CMS interprets the ARP requirements to 
cover treatments specifically for COVID-19 to establish a requirement that is similar to the 
Medicaid Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirement at 
section 1905(r)(5) of the Act.  That is, CMS interprets this language to require states to cover any 
non-pharmacological item or service described in section 1905(a) of the Act in Medicaid, and any 
non-pharmacological item or service described in section 2110(a) of the Act in CHIP, that is 
medically necessary for treatment of COVID-19. 
                                                           
Secretary are attributable to administrative costs related to providing for medical assistance to this group under the 
state plan, are matched at 100 percent. 
5 CDC guidance on post-COVID conditions is available at: https://www.cdc.gov/coronavirus/2019-ncov/long-term-
effects.html.   
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 3  State Health Official 
 
   
States will thus need to establish medical necessity criteria, which may incorporate standards of 
care developed in consultation with recognized medical organizations involved in COVID-19 
treatment and care, or otherwise incorporate the judgment of health care professionals, to 
determine whether a non-pharmacological item or service must be covered under the ARP 
amendments, and can opt to establish other utilization management controls, consistent with 42 
CFR  440.230 and 457.490.  Given the breadth of the new coverage requirements established in 
the ARP, and the beneficiary-specific medical decisions that must be made in the treatment of 
COVID-19, states should ensure that the determination of whether a non-pharmacological item or 
service is medically necessary for treatment of COVID-19 is made on a case-by-case basis, and 
that it takes into account the particular treatment needs of the individual and the judgment of 
health care professionals.  Additionally, the medical necessity criteria that states establish to 
determine when a non-pharmacological item or service must be covered, without cost-sharing, 
under the ARP amendments, and any utilization management controls that states apply to that 
coverage, should not establish unreasonable or arbitrary barriers to accessing the required 
coverage.   
 
With respect to pharmacological treatments, CMS interprets these ARP amendments to require 
coverage of any drug or biological that is approved (or licensed) by the U.S. Food & Drug 
Administration (FDA)6 or authorized by the FDA under an Emergency Use Authorization (EUA) 
to treat or prevent COVID-19, consistent with the applicable authorizations. Section 9811(a)(4) of 
the ARP expressly provides for the inclusion of covered outpatient drugs used for COVID-19 
treatment in the Medicaid Drug Rebate Program.  More specifically, the requirements of section 
1927 of the Act apply to drugs and biological products furnished as medical assistance for 
COVID-19-related treatment that satisfy the definition of a covered outpatient drug.  Thus, a state 
may subject any COVID-19 treatment that is a covered outpatient drug to a utilization 
management approach, consistent with section 1927(d) of the Act, or drug utilization review 
consistent with section 1927(g).  Again, any utilization management controls states apply to drugs 
or biologicals covered as treatment of COVID-19 should not establish unreasonable or arbitrary 
barriers to accessing coverage.  
  
States might apply limitations on the amount, duration, or scope of coverage of items or services 
(including drugs) when those items or services are covered to treat or prevent conditions other 
than COVID-19.  If a state does so, it should not apply those limits when the item or service is 
covered under the ARP amendments because it is needed to treat or prevent COVID-19.  
However, (as discussed above) states may apply utilization management controls specifically 
when the item or service is covered as treatment for COVID-19. 
  
CMS does not interpret the references to preventive therapies in sections 1905(a)(4)(F), 
2103(c)(11)(B), or the related amendments that ARP sections 9811 and 9821 made to the Act, to 
include COVID-19 vaccines or their administration. That is because, in a separate set of 
amendments to the Act, sections 9811 and 9821 of the ARP require state Medicaid and CHIP 
                                                           
6 Licensed is the statutory term under section 351 of the Public Health Service Act for what is commonly referred 
to as approval of a biological product. Hereinafter, this SHO Letter will reference FDA approval and licensure 
collectively as approvals.  
 
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 4  State Health Official 
 
programs to cover COVID-19 vaccines and their administration without cost sharing, for a 
broader range of beneficiaries than the COVID-19-related treatment coverage requirements in 
sections 9811 and 9821 of the ARP.7 As preventive treatments or therapies for COVID-19 (other 
than COVID-19 vaccines and their administration) become available, they too would be required 
to be covered as described above. 
  
Pharmacological Treatments for COVID-19  
 
Several pharmacological therapies to treat COVID-19 have been FDA approved or authorized 
under an EUA.  When the Secretary of Health and Human Services declares that an emergency 
justifies emergency use of a product, the FDA may authorize the use of unapproved drugs or 
authorize unapproved uses of approved drugs under certain conditions (such as to be used in 
specific health care settings), pursuant to FDAs emergency authorities as described in section 
564 of the Federal Food, Drug, and Cosmetic Act (FFDCA). In addition to the therapies currently 
approved or authorized by the FDA, many more products are being tested in clinical trials and 
will be reviewed by FDA to evaluate whether they are safe and effective in combating or 
preventing COVID-19.  
  
Under the ARP requirement to cover treatments (including preventive therapies) specifically for 
COVID-19, states would be expected to cover FDA-approved drugs and FDA-licensed 
biologicals to treat or prevent COVID-19, FDA-approved drugs and FDA-licensed biologicals 
that have an indication to treat or prevent COVID-19 that is authorized under an EUA, and 
unapproved drugs that the FDA has specifically authorized to be used to treat or prevent COVID-
19 under an EUA.   
 
Mandatory coverage under the ARP includes coverage for monoclonal antibodies (mAbs) when 
specifically approved by the FDA to treat or prevent COVID-19, or authorized by the FDA under 
an EUA to be used for the specific conditions and specific settings to treat or prevent COVID-19, 
including when such authorizations would permit infusion in the home setting.8  States will find 
the latest information regarding these mAbs found at the FDA website listed below.  
 
The Public Readiness and Emergency Preparedness (PREP) Act authorizes the Secretary of 
Health and Human Services (Secretary) to issue a declaration (PREP Act declaration) that 
provides immunity from suit and liability (except for willful misconduct) for claims of loss 
caused by, arising out of, relating to, or resulting from administration or use of covered 
countermeasures to diseases, health conditions, or other threats to health determined by the 
Secretary to constitute a present, or credible risk of a future public health emergency.  Immunity 
extends to entities and individuals involved in (among other activities) the administration and use 
of such countermeasures.   
 
                                                           
7 For more information on Medicaid and CHIP coverage and reimbursement of COVID-19 vaccines and their 
administration under the ARP, please see CMS guidance at https://www.medicaid.gov/state-resource-
center/downloads/covid-19-vaccine-toolkit.pdf. 
8 As of the date of this letter, there are no monoclonal antibodies approved by the FDA to treat or prevent COVID-19, 
rather only certain monoclonal antibodies authorized under an FDA EUA. For more information see: 
https://www.fda.gov/emergency-preparedness-and-response/mcm-legal-regulatory-and-policy-
framework/emergency-use-authorization 
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 5  State Health Official 
 
On March 10, 2020, the Secretary issued a PREP Act declaration, effective February 4, 2020, to 
provide liability protections for activities related to medical countermeasures against COVID-19 
(HHS COVID-19 PREP Act declaration).  HHS published a ninth amendment to the HHS 
COVID-19 PREP Act declaration on September 14, 2021.  Under this ninth amendment, licensed 
pharmacists can now order and administer COVID-19 therapeutics (such as monoclonal 
antibodies) subcutaneously, intramuscularly, or orally, as authorized, approved, or licensed by the 
FDA.  Additionally, under this ninth amendment, qualified pharmacy technicians and licensed or 
registered pharmacy interns can also administer COVID-19 therapeutics as authorized, approved, 
or licensed by the FDA.9  A number of criteria (stated in the declaration) must be met in order for 
these professionals to be considered to be qualified persons authorized under the HHS COVID-
19 PREP Act declaration to order and/or administer COVID-19 therapeutics.  As discussed in the 
ninth amendment, any state law that would otherwise prohibit these healthcare professionals who 
are a qualified person from prescribing, dispensing, or administering COVID-19 therapeutics is 
preempted.10  CMS expects to provide more information to states soon about the implications of 
the ninth amendment to the HHS COVID-19 PREP Act declaration for Medicaid and CHIP 
coverage of COVID-19 therapeutics that are administered subcutaneously, intramuscularly, or 
orally.  We anticipate that the Medicaid and CHIP coverage implications of this amendment will 
be similar to the implications for Medicaid and CHIP coverage of the HHS COVID-19 PREP Act 
declaration and authorizations related to ordering and administering COVID-19 vaccines.11   
     
As explained above, section 9811(a)(4) of the ARP provides for the inclusion in the Medicaid 
Drug Rebate Program of covered outpatient drugs used for COVID-19 treatment.  More 
specifically, section 9811(a)(4) of the ARP provides for the requirements of section 1927 of the 
Act to apply to any drug or biological to which section 1905(a)(4)(F) of the Act applies, or to 
which the language adding COVID-19-related treatment to the coverage for the optional COVID-
19 group applies, that is a covered outpatient drug and furnished as medical assistance in 
accordance with sections 1902(a)(10)(A) and 1905(a)(4)(F) of the Act or the language adding 
COVID-19-related treatment to the coverage for the optional COVID-19 group.  In determining 
whether such a drug or biological product satisfies the definition of a covered outpatient drug at 
section 1927(k)(2) of the Act, ARP section 9811(a)(4)(A)(ii) provides that such drugs are deemed 
to be prescribed drugs for the purposes of section 1905(a)(12) and meeting the introductory 
language for the definition of a covered outpatient drug at section 1927(k)(2)(A). Thus, if a drug 
or biological furnished as medical assistance in accordance with sections 1902(a)(10)(A) and 
1905(a)(4)(F) or the language adding COVID-19-related treatment to the coverage for the 
optional COVID-19 group meets the definition of a covered outpatient drug, it is included in the 
Medicaid Drug Rebate Program, section 1927 of the Act applies, and such drugs and biologicals 
would be subject to applicable rebates.   
 
                                                           
9 Ninth Amendment to Declaration Under the Public Readiness and Emergency Preparedness Act for Medical 
Countermeasures Against COVID-19, 86 Fed. Reg. 51160 (Sept. 14, 2021), at 
https://www.federalregister.gov/documents/2021/09/14/2021-19790/ninth-amendment-to-declaration-under-the-
public-readiness-and-emergency-preparedness-act-for-medical.  
10 See id. at 51162-63. 
11 See discussion in section V of the CMS guidance available at https://www.medicaid.gov/state-resource-
center/downloads/covid-19-vaccine-toolkit.pdf for more information on the Medicaid and CHIP coverage 
implications of the HHS COVID-19 PREP Act declaration and authorizations related to ordering and administering 
COVID-19 vaccines.  
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 6  State Health Official 
 
The requirements of section 1927 would not apply to drugs and biologicals used to prevent or 
treat COVID-19 that do not meet the definition of a covered outpatient drug, although such drugs 
and biologicals would be subject to the ARPs coverage requirements (and states could receive 
federal financial participation in their expenditures to cover them).  In such cases where the 
requirements of section 1927 would not apply, any such drugs and biologicals used to prevent or 
treat COVID-19 would not be subject to applicable rebates.  For example, a drug that is only 
authorized to be used under an EUA described in section 564 of the FFDCA to treat or prevent 
COVID-19 would not meet the definition of covered outpatient drug under section 1927, and as a 
result, section 1927 requirements would not apply, and the drug would not be eligible for a 
manufacturer rebate. 
    
Non-Pharmacological Treatments for COVID-19  
 
As explained above, to comply with the coverage requirements in sections 9811 and 9821 of the 
ARP, states must cover any non-pharmacological item or service described in section 1905(a) and 
2110(a) of the Act that is medically necessary for treatment of COVID-19, including specialized 
equipment and therapies (including preventive therapies).  States may already cover a wide array 
of non-pharmacological treatments for COVID-19 through mandatory and optional Medicaid and 
CHIP benefits such as inpatient hospital services, outpatient hospital services, federally-qualified 
health center services, physician services, home health care services, services of other licensed 
practitioners, and freestanding clinic services.  If a state does not already cover non-
pharmacological items and services to treat COVID-19, the state must now provide coverage for 
those items and services to comply with the ARP requirements and must cover these items and 
services without cost sharing, and may need to amend its state plan to add this coverage.  
 
As discussed above, states will have to implement medical necessity criteria and can opt to 
implement other utilization management controls consistent with 42 CFR  440.230 and 457.490 
as long as they do not establish unreasonable or arbitrary barriers to accessing the required 
coverage.  Additionally, as indicated above, any limit typically placed on the amount, duration, or 
scope of coverage of an item or service when it is covered for purposes other than treatment for 
COVID-19 should not be applied if the item or service is covered under the ARP amendments 
because it is needed to treat COVID-19. However, (as discussed above) states can apply 
utilization management controls specifically when the item or service is covered as treatment for 
COVID-19. 
 
Treatments for a Condition that May Seriously Complicate COVID-19 Treatment 
 
The coverage required under ARP sections 9811 and 9821 includes not only treatments and 
preventions specifically for COVID-19 (discussed above), but also, during the period when a 
beneficiary is diagnosed with or is presumed to have COVID-19, treatment of a condition that 
may seriously complicate COVID-19 treatment for such a beneficiary.  Medicaid and CHIP 
beneficiaries with certain underlying comorbidities are at a higher risk of progressing to severe 
COVID-19, or have conditions that could seriously complicate the treatment of COVID-19.  
Examples of these conditions include, but are not limited to, cardiovascular diseases, chronic lung 
diseases, diabetes, cancer, obesity, Down Syndrome, and being a recipient of a transplant or 
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 7  State Health Official 
 
immunosuppressive therapy.12 Whether a beneficiary has a condition that could seriously 
complicate the treatment of COVID-19 should be determined based on a beneficiary-specific 
assessment.  
       
This coverage of treatment of a condition that may seriously complicate the treatment of COVID-
19 is extremely broad, and encompasses a wide array of possible treatments and therapies, 
including hundreds of drugs, but this component of the mandatory benefit includes only services 
that are otherwise covered under the state plan(s) or a waiver of the plan(s) (including a section 
1115 demonstration) (which CMS will interpret to mean the services covered by the state as of 
the date of the enactment of the ARP, March 11, 2021). 
  
Therefore, states are not required to provide new coverage under their Medicaid or CHIP 
programs in order to comply with this part of the ARP coverage requirements.  However, states 
will need to determine when an item or service should be covered without cost-sharing for a 
beneficiary, and without limits on amount, duration, or scope that would otherwise apply when 
the item or service is covered for other purposes.  States may apply utilization management 
controls specifically when the item or service is covered as COVID-19-related treatment, 
including as treatment for a condition that may seriously complicate the treatment of COVID-19, 
provided that in doing so, states do not establish unreasonable or unnecessary barriers to 
accessing coverage.  
      
Even though this component of the new ARP coverage does not require states to add new 
coverage to their Medicaid or CHIP programs, states may always choose to add new coverage to 
their programs, including in order to cover treatments of conditions that may complicate the 
treatment of COVID-19.  
  
Additionally, as noted above, section 1927 of the Act and the Medicaid Drug Rebate Program 
requirements apply to any such drugs or biologicals furnished as medical assistance in accordance 
with sections 1902(a)(10)(A) and 1905(a)(4)(F) of the Act or the language adding COVID-19-
related treatment to the coverage for the optional COVID-19 group, which satisfy the definition of 
a covered outpatient drug. 
 
Exemption of COVID-19-Related Treatment Services from Cost Sharing  
 
How states opt to effectuate the cost sharing exemptions in ARP sections 9811 and 9821 will 
depend on the Medicaid and CHIP cost sharing in effect in the state before those exemptions took 
effect.  If, before March 11, 2021, a state imposed cost sharing for any of the items or services 
(including drugs) that states are required to cover under the ARP amendments, it must stop doing 
so effective March 11, 2021.  If a state continued imposing such cost sharing after March 11, 
2021, the state must take all reasonable steps available to the state to ensure that providers 
reimburse beneficiaries for the amount of the unauthorized cost sharing imposed after that date 
and that reimbursement to providers is not reduced by the amount of the unauthorized cost 
sharing imposed after that date.  
 
                                                           
12 See https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html  
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incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law. 
  Page 8  State Health Official 
 
Because the statutory language describing the mandatory coverage is the same as the statutory 
language describing the cost-sharing exemptions, states must generally align their implementation 
of the cost-sharing exemptions with their implementation of the corresponding coverage 
requirements.  As discussed above, states should ensure that the determination of whether a non-
pharmacological item or service is considered to be treatment or prevention specifically for 
COVID-19 is made on a case-by-case basis and that it takes into account the particular treatment 
needs of the individual and the judgment of health care professionals. Additionally, states must 
cover, under these ARP amendments, any drug or biological that has an FDA-approved or FDA-
authorized use for treatment or prevention of COVID-19, consistent with the applicable 
authorizations.  And, whether an item or service (including drugs) is a treatment for a condition 
that may seriously complicate COVID-19 treatment during the period when a beneficiary is 
diagnosed with or is presumed to have COVID-19 should be determined on a case-by-case basis.  
 
Providers may not impose any otherwise applicable cost sharing for any items or services 
(including drugs) that states must cover without cost-sharing under these ARP provisions.  
Additionally, states must reimburse providers using the full payment rate for the items or services 
provided (i.e., not reduce the providers payment by the amount of any cost sharing).  That said, 
any state can opt to suspend cost-sharing for all Medicaid and CHIP services, and if a state does 
so, it would necessarily also comply with the ARP cost-sharing exemptions.   
 
Submission of State Plan Amendments to Implement ARP Requirements  
 
As noted above, many of the COVID-19-related treatments that states are required to cover 
without cost sharing under ARP sections 9811 and 9821 will already be included under other 
benefits in the state plan or a waiver of the plan (including a section 1115 demonstration). Indeed, 
this will always be the case with respect to the required coverage for treatment of a condition that 
may seriously complicate the treatment of COVID-19.  However, states might cover some such 
benefits under amount, duration, and scope parameters, or with cost-sharing obligations, that are 
not permissible with respect to the COVID-19-related treatment coverage requirements in the 
ARP. 
      
Accordingly, to ensure that all states state plans reflect the statutory requirements, states must 
submit a Medicaid state plan amendment (SPA) attesting to coverage and reimbursement of 
COVID-19-related treatments without cost-sharing, in accordance with sections 1905(a)(4)(F), 
1937(b)(8)(B), 1916(a)(2)(I), 1916(b)(2)(I), and 1916A(b)(3)(B)(xiii) of the Act, and without 
amount, duration, or scope limitations that would otherwise apply when items and services are 
covered for purposes other than COVID-19-related treatment.  If states are covering the optional 
COVID-19 group described at section 1902(a)(10)(A)(ii)(XXIII) of the Act, they may also need 
to amend the state plan to reflect the ARPs amendments to the coverage that states provide to 
members of that group. States may also need to amend the Medicaid state plan to include payment 
methodologies for items and services covered under the amendments made by ARP section 9811. 
 
States must also submit a CHIP SPA pursuant to CMS requirements at 42 CFR  457.60(a). 
States will need to indicate that they are providing coverage of COVID-19-related treatments 
without cost sharing or amount, duration, or scope limitations that would otherwise apply when 
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 9  State Health Official 
items and services are covered for purposes other than COVID-19-related treatment, in 
accordance with the requirements of section 2103(c)(11)(B) and 2103(e)(2) of the Act.  
States may also need to amend their Medicaid or CHIP state plans to add coverage of treatments 
specifically for COVID-19 that are not already covered in the state plan. 
CMS will provide additional information on submission of Medicaid and CHIP SPAs to reflect 
ARP changes and is available to provide technical assistance on SPA development. 
Conclusion 
This guidance describes provisions of the ARP that require state Medicaid and CHIP programs to 
cover COVID-19-related treatment without cost sharing. As previously stated, CMS will apply 
the statutory interpretations in this guidance on a prospective basis beginning with the date of 
issuance of this letter.  Please contact John M. Coster, Director of the Division of Pharmacy, at 
John.Coster@cms.hhs.gov for additional information on prescribed drug issues, Kirsten Jensen, 
Director of the Division of Benefits and Coverage, at Kirsten.Jensen@cms.hhs.gov for non-
pharmacological issues, and Meg Barry, Director of the Division of State Coverage Programs at 
Meg.Barry@cms.hhs.gov, for CHIP issues. 
Sincerely,
Daniel Tsai
Deputy Administrator and Director     
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.