Coronavirus (COVID-19) Pandemic: 

Medical Care Costs Eligible for Public 

Assistance 

FEMA Policy FP 104-010-04 

BACKGROUND 

Under the President’s March 13, 2020 COVID-19 emergency declaration1 and subsequent 

major disaster declarations for COVID-19, state, local, tribal, and territorial (SLTT) government 

entities and certain private non-profit (PNP) organizations are eligible to apply for assistance 

under the FEMA Public Assistance (PA) Program. This policy is applicable to eligible PA 

Applicants only and is exclusive to emergency and major disaster declarations for the COVID19 pandemic. 

PURPOSE 

This policy defines the framework, policy details, and requirements for determining the 

eligibility of medical care costs under the PA Program to ensure consistent and appropriate 

implementation across all COVID-19 emergency and major disaster declarations. Except 

where specifically stated otherwise in this policy, assistance is subject to PA Program 

requirements as defined in Version 3.1 of the Public Assistance Program and Policy Guide 

(PAPPG).2 

PRINCIPLES 

A. FEMA will provide assistance for medical care provided under COVID-19 declarations to 

improve the abilities of communities to effectively respond to the COVID-19 Public Health 

Emergency. 

B. FEMA will implement this policy and any assistance provided in a consistent manner 

through informed decision making and review of an Applicant’s supporting documentation. 

C. FEMA will engage with interagency partners, including the U.S. Department of Health and 

Human Services’ (HHS) Office of the Assistant Secretary for Preparedness and Response 

(ASPR) and the Centers for Disease Control and Prevention (CDC), the Health Resources 

1 www.fema.gov/news-release/2020/03/13/covid-19-emergency-declaration. 2 The current version of the Public Assistance Program and Policy Guide (PAPPG), Version 3.1, is available on the FEMA 

website at www.fema.gov/media-library/assets/documents/111781. 

FEMA Policy FP 104-010-04 Page 1 of 10 
 

 

and Services Administration (HRSA), and the Centers for Medicare and Medicaid Services 

(CMS) to ensure this assistance is provided in a coordinated manner without duplicating 

assistance. 

REQUIREMENTS 

A. APPLICABILITY 

Outcome: To establish the parameters of this policy and ensure it is implemented in a manner 

consistent with program authorities and appropriate to the needs of the COVID-19 Public 

Health Emergency. 

1. This policy applies to: 

a. All Presidential emergency and major disaster declarations under the Robert T. 

Stafford Disaster Relief and Emergency Assistance Act (Stafford Act), as amended, 

issued for the COVID-19 Public Health Emergency. 

b. Eligible PA Applicants under the COVID-19 emergency declaration or any 

subsequent COVID-19 major disaster declaration, including: 

i. SLTT government entities; and 

ii. PNP organizations that own and/or operate medical facilities, as defined in 

Title 44 of the Code of Federal Regulations (44 C.F.R.) §206.221(e)(5). 

c. This policy does not apply to any other emergency or major disaster declaration. 

B. GENERAL ELIGIBILITY CONSIDERATIONS FOR COVID-19 MEDICAL CARE 

Outcome: To define the overarching framework for all eligible medical care work related to 

COVID-19 declarations. 

1. All work must be necessary as a direct result of the emergency or major disaster in 

accordance with 44 C.F.R. §206.223(a)(1). 

2. Medical care and associated costs refer to assistance to support the provision of medical 

care, including eligible facility, equipment, supplies, staffing, and wraparound services (as 

defined in the Definitions section at the end of this document), as well as assistance for 

clinical care of patients not covered by another funding source as described throughout this 

policy. 

C. ELIGIBLE MEDICAL CARE WORK AND COSTS BY FACILITY TYPE 

Outcome: To establish parameters for eligible medical care work and costs for COVID-19 

declarations based on the type of facility providing medical care. 

1. Primary Medical Care Facility. 

For medical care provided in a primary medical care facility (as defined in the Definitions 

section at the end of this document), work must be directly related to the treatment of 

FEMA Policy FP 104-010-04 Page 2 of 10 
 

COVID-19 patients. Work may include both emergency and inpatient treatment of COVID19 patients; this includes both confirmed and suspected cases of COVID-19. Medical care 

related to treatment of a non-COVID-19 illness or injury in a primary medical care facility is 

not eligible. The following medical care activities and associated costs are eligible in 

primary medical care facilities: 

a. Emergency and inpatient clinical care for COVID-19 patients, including, but not 

limited to: 

i. Emergency medical transport related to COVID-19; 

ii. Triage and medically necessary tests and diagnosis related to COVID-19 

patients; 

iii. Necessary medical treatment of COVID-19 patients; and 

iv. Prescription costs related to COVID-19 treatment. 

b. Purchase, lease, and delivery of specialized medical equipment necessary to 

respond to COVID-19 (equipment purchases are subject to disposition 

requirements3); 

c. Purchase and delivery of PPE, durable medical equipment, and consumable medical 

supplies necessary to respond to COVID-19 (supply purchases are subject to 

disposition requirements4); 

i. This includes the costs of eligible SLTT government Applicants providing PPE 

to any public or private medical care facility that treats COVID-19 patients. 

d. Medical waste disposal related to COVID-19; and 

e. Certain labor costs associated with medical staff providing treatment to COVID-19 

patients may be eligible as outlined below. Any labor costs for medical staff that are 

included in patient billing and/or otherwise covered by another funding source (as 

described in Section D.4 Duplication of Benefits of this policy) are not eligible for 

PA. Otherwise, the following labor costs may be eligible: 

i. Overtime for budgeted medical staff providing treatment to COVID-19 

patients; 

ii. Straight time and overtime for temporary medical staff providing treatment to 

COVID-19 patients; and 

iii. Straight time, overtime, and other necessary costs for contract medical staff 

providing treatment to COVID-19 patients. Work and associated costs must 

be consistent with the scope of the contract and may include costs for travel, 

lodging, and per diem for contract medical staff from outside the local 

commuting area. 

3 As described in Chapter 2:V.E. Disposition of Purchased Equipment and Supplies of the PAPPG (V3.1). 

4 Id. 

FEMA Policy FP 104-010-04 Page 3 of 10 
f. For primary medical care facilities, increased operating costs for administrative 

activities (such as medical billing) are not eligible.5 

2. Temporary and Expanded Medical Facilities.6 

FEMA may approve work and costs associated with temporary medical facilities or 

expanded medical facilities when necessary in response to the COVID-19 Public Health 

Emergency. These facilities may be used to treat COVID-19 patients, non-COVID-19 

patients, or both, as necessary. Medical care activities and associated costs related to 

treating both COVID-19 and non-COVID-19 patients in a temporary or expanded medical 

facility may be eligible. 

a. Costs must be reasonable and necessary based on the actual or projected need. The 

projected needs (i.e., capacity and capability) for a temporary or expanded medical 

facility must be supported by predictive modeling or other substantiating information 

used to determine the projected need. 

b. Eligible costs for temporary and expanded medical facilities include: 

i. All eligible items and stipulations included in Section C.1 Primary Medical 

Care Facility, but applicable to both COVID-19 and non-COVID-19 patients; 

ii. Lease, purchase, or construction costs, as reasonable and necessary, of a 

temporary facility as well as reasonable alterations to a facility necessary to 

provide medical care services;7 

iii. Mobilization and demobilization costs associated with setting up and closing 

the temporary or expanded medical facility; 

iv. Operating costs including equipment, supplies, staffing, wraparound services 

(as defined in the Definitions section at the end of this document), and clinical 

care not covered by another funding source; and 

v. Maintenance of a temporary or expanded medical facility in an operationally 

ready but unused status available for surge capacity for COVID-19 readiness 

and response when necessary to eliminate or lesson an immediate threat to 

public health and safety, based on public health guidance, location of areas 

expected to be impacted, and local/state hospital bed/ICU capacity. 

c. For contract costs related to establishing and/or operating a temporary or expanded 

medical facility, contracts must include a termination for convenience clause that will 

be implemented if the site is ultimately not needed, or the needs are less than 

projected, as determined by the legally responsible entity. 

i. Ongoing and projected needs regarding continuing operations at a temporary 

or expanded medical facility should be based on regular assessments and the 

Applicant must document the review process to support its decision making. 

5 See Chapter 2:VI.B.2. Expenses Related to Operating a Facility or Providing a Service of the PAPPG (V3.1). 

6 Temporary medical facilities may include Alternate Care Sites or Community Based Testing Sites if eligible work and 

costs related to these facilities are incurred by eligible PA Applicants. 

7 As described in Chapter 2:VI.B.17(e) and (g) of the PAPPG (V3.1). 

FEMA Policy FP 104-010-04 Page 4 of 10 
 

ii. The assessments should include adjustments to projected needs based on 

guidance from public health officials, caseload trends, and/or other predictive 

modeling or methodologies; lead times and associated costs for scaling up or 

down based on projected needs; and any other supporting information. 

iii. The assessments and supporting information are necessary to determine 

eligibility of claimed costs and should align with PA reasonable cost guidance 

provided in the PAPPG8 and the Public Assistance Reasonable Cost 

9 Evaluation Job Aid. 

d. Costs related to expanding a primary medical care facility to effectively respond to 

COVID-19 must be feasible and cost effective. In most cases, permanent 

renovations are not eligible unless the Applicant can demonstrate that the work can 

be completed in time to address COVID-19 capacity needs and is the most costeffective option. Permanent renovations and other improvements to real property 

with PA funds are subject to real property disposition requirements.10 

e. For temporary and expanded medical facilities, and the specific type of temporary 

medical facilities known as Alternate Care Sites, administrative activities and 

associated costs necessary for the provision of essential medical services are 

eligible. 

D. GENERAL ELIGIBILITY CONSIDERATIONS FOR COVID-19 COSTS 

Outcome: To provide additional information about eligible costs and cost-related 

considerations. 

1. Eligible claimed costs must be necessary in order to respond to the COVID-19 Public 

Health Emergency and reasonable pursuant to Federal regulations and Federal cost 

principles.11 A cost is considered reasonable if, in its nature and amount, it does not exceed 

that which would be incurred by a prudent person under the circumstances prevailing at the 

time the decision was made to incur the cost. All costs are subject to standard PA program 

eligibility and other Federal requirements. For COVID-19 declarations, FEMA will use 

Medicare rates12 as the basis to determine reasonable costs for eligible clinical care not 

covered by another funding source. Both patient payments and insurance payments are 

considered another funding source; clinical care for which providers have received or will 

receive payments from patients or insurance is not eligible. 

2. Cost Share for COVID-19 Declarations. PA funding authorized under COVID-19 

declarations is subject to the following cost share provisions: 

8 As described in Chapter 2:V. Cost Eligibility of the PAPPG (V3.1). 

9 The Public Assistance Reasonable Cost Evaluation Job Aid is available on the FEMA website at www.fema.gov/medialibrary/assets/documents/90743. 10 As described in Chapter 2:V.F. Disposition of Real Property of the PAPPG (V3.1). 

11 2 CFR §200.404. 

12 FEMA will use standard Medicare rates that do not include the 20 percent increase in COVID-19 Medicare DRG rates 

implemented by the CARES Act. 

FEMA Policy FP 104-010-04 Page 5 of 10 
 

 

a. Eligible costs incurred by an eligible Applicant claiming reimbursement through PA 

are subject to the non-federal cost share established for the respective emergency 

or major disaster declaration. Pursuant to sections 403(b) and 503(a) of the Stafford 

Act, the federal share for FEMA PA funding is not less than 75 percent of eligible 

costs. 

b. Direct Federal Assistance provided under Stafford Act authorities is also subject to 

the cost share established for the respective emergency or major disaster 

declaration, unless otherwise stipulated. 

c. Federal assistance provided by other federal departments and agencies, including 

instances in which provision of the assistance is facilitated by FEMA, is funded at the 

cost share of the other federal department or agency, some of which may be 

provided at 100 percent federal funding. 

d. In most cases, federal assistance provided by other federal departments and 

agencies cannot be used to cover the non-federal cost share. The Applicant can 

only apply other federal award funds toward the PA non-federal cost share if the 

other federal award has specific statutory authority allowing it to be utilized to meet 

cost-share requirements, or is otherwise allowable under the other federal source of 

funding. 

e. The Applicant cannot apply PA funds toward the non-federal cost share of other 

federal agency funding. For example, States may not use PA funding to meet the 

State share of Medicaid or the Children’s Health Insurance Program (CHIP).13 

3. Procurement Requirements for COVID-19 Declarations.14 

a. States and territorial governments are required to follow their own procurement 

procedures as well as the Federal requirements for procurement of recovered 

materials and inclusion of required contract provisions per 2 C.F.R. §§ 200.317, 

200.322, and 200.326 and Appendix II to 2 CFR Part 200.15 

b. Tribal governments, local governments, and PNPs must comply with the 

requirements of 2 C.F.R. §§ 200.318-200.326. 

c. In accordance with the March 17, 2020, memorandum from David Bibo, Acting 

Associate Administrator for the Office of Response and Recovery, and Bridget E. 

Bean, Assistant Administrator, Grant Programs Directorate, for the duration of the 

Public Health Emergency, as determined by HHS, local governments, tribal 

13 See 42 C.F.R. § 433.51 and 45 C.F.R. § 75.306. 14 Additional guidance regarding procurement standards is available at https://www.fema.gov/procurement-disasterassistance-team. 15 For additional guidance regarding required contract clauses, see the Procurement Disaster Assistance Team’s “FEMA 

Contract Provisions Template” (2019 ed.), available online at https://www.fema.gov/media-library-data/1569959119092-

92358d63e00d17639d5db4de015184c9/PDAT_ContractProvisionsTemplate_9-30-19.pdf. 

FEMA Policy FP 104-010-04 Page 6 of 10 
 

governments, nonprofits, and other non-state entities may proceed with new and 

existing non-competitively procured contracts using the exigent/emergency 

circumstances exception in 2 C.F.R. § 200.320(f)(2). The March 17, 2020 

memorandum and other information related to procurement specific to COVID-19 

declarations are available on the FEMA website at www.fema.gov/medialibrary/assets/documents/186350. Additional resources on COVID-19 specific to 

grants are also available at www.fema.gov/grants under “News and Announcements” 

and www.fema.gov/coronavirus. 

d. SLTT governments may contract with medical providers, including private entities, to 

carry out any eligible activity described in Section C. Eligible Medical Care by 

Facility of this policy. 

e. Contracts must include an actionable termination for convenience clause that will be 

implemented if any part of the scope of the contract is ultimately not needed, or the 

needs are less than projected, as determined by the legally responsible entity. 

Ongoing and projected needs should be based on regular reviews and the Applicant 

must document the review process to support its decision making. All claimed 

contract costs must be necessary and reasonable pursuant to applicable Federal 

regulations and Federal cost principles. 

4. Duplication of Benefits. 

Pursuant to Section 312 of the Stafford Act, FEMA is prohibited from providing financial 

assistance where such assistance would duplicate funding available from another program, 

insurance, or any other source for the same purpose. 

a. FEMA cannot duplicate assistance provided by HHS or other federal departments 

and agencies. This includes, but is not limited to, funding provided by the programs 

listed below. FEMA is providing this list as a helpful reference, but SLTT government 

entities and PNPs should consult with the appropriate federal agency and the terms 

and conditions of each program or source of funding to determine what funding may 

be considered duplicative. 

i. The Public Health Emergency Preparedness Cooperative Agreement 

Program; 

ii. The Public Health Crisis Response Cooperative Agreement; 

iii. The Epidemiology and Laboratory Capacity for Prevention and Control of 

Emerging Infectious Diseases; 

iv. The Hospital Preparedness Program Cooperative Agreement; 

v. The Regional Ebola and Other Special Pathogen Treatment Centers 

Cooperative Agreement; 

vi. The National Emerging Special Pathogens Training and Education Center 

Cooperative Agreement; 

vii. The Hospital Association COVID-19 Preparedness and Response Activities 

Cooperative Agreement; 

viii. The Coronavirus Relief Fund and the Provider Relief Fund; 

FEMA Policy FP 104-010-04 Page 7 of 10 
____________________________________ 

ix. The COVID-19 Uninsured Program; and 

x. The Paycheck Protection Program. 

b. FEMA cannot provide PA funding for clinical care costs funded by another source, 

including private insurance, Medicare, Medicaid/CHIP, other public insurance, a preexisting private payment agreement, or the COVID-19 Uninsured Program for 

uninsured patients.16 The Applicant will certify that it has not received and does not 

anticipate receiving assistance from these sources or any other source for the same 

work or costs. FEMA will deobligate any PA funding that has been provided in the 

event that another source provides funds to the Applicant for the same clinical care 

costs. 

c. At no time will FEMA request or accept any Personally Identifiable Information related 

to the medical care of individual COVID-19 patients. 

d. FEMA will reconcile final funding based on any funding provided by another agency 

or covered by insurance or any other source for the same purpose. FEMA will 

coordinate with HHS to share information about funding from each agency to assist in 

preventing duplication of benefits. 

5. Time Limitations for the Completion of Work. 

a. Costs for eligible medical care for COVID-19 declarations are limited to those 

incurred within six months of the date of the declaration in accordance with regulatory 

timeframes for emergency work at 44 C.F.R. §206.204(c) or until the end of the 

COVID-19 Public Health Emergency, whichever comes first. 

b. For all COVID-19 declarations, FEMA may extend the deadline in accordance with 44 

C.F.R. §206.204(d) if the duration of the COVID-19 Public Health Emergency extends 

beyond six months or for work required after the end of the Public Health Emergency, 

such as demobilization of temporary medical facilities, or to address localized needs 

as appropriate. 

____________________________________ 

Keith Turi 

Assistant Administrator, Recovery Directorate 

May 9, 2020 

Date 

16 The COVID-19 Uninsured Program reimburses for testing and clinical care costs for the uninsured which is being 

provided at Medicare rates. 

FEMA Policy FP 104-010-04 Page 8 of 10 
 

ADDITIONAL INFORMATION 

REVIEW CYCLE 

This policy will be reviewed periodically during the COVID-19 Public Health Emergency period. 

The Assistant Administrator for the Recovery Directorate is responsible for authorizing any 

changes or updates. This policy will sunset with the closure of the national emergency 

declaration for COVID-19 and any subsequent major disaster declarations for COVID-19. 

AUTHORITIES and REFERENCES 

Authorities 

• Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. § 5121-5207, 

as amended 

• Title 44 of the Code of Federal Regulations, Part 206, Subpart H 

• Title 2 of the Code of Federal Regulations, Part 200 

References 

• Public Assistance Program and Policy Guide, Version 3.1 

DEFINITIONS 

To establish consistent terminology for purposes of implementing this policy, the following 

definitions are provided below. These definitions are specific to this policy and may differ from 

definitions prescribed for the same or similar terms in other policies. 

1. Medical Care: Medical Care refers both to assistance provided to support the provision of

medical care and assistance for clinical care. Examples of medical care support include

eligible facility, equipment, supplies, and staffing costs.

2. Clinical Care: Clinical Care refers to medical treatment of individual patients including

testing, diagnosis, treatment, hospitalization, prescriptions, and other costs associated with

individual patient treatment typically billed to individual patients, their insurance carriers,

Medicare, Medicaid, or other pre-existing payment agreements.

3. Primary Medical Care Facility: A primary medical care facility is the facility owned and/or

operated by an eligible PA Applicant that provides medical care services. This includes any

licensed hospital, outpatient facility, rehabilitation facility, or facility for long-term care.

4. Temporary Medical Facility: A temporary medical facility is a facility separate from the

primary medical care facility that is used to provide medical care services when the primary

medical care facility is overwhelmed by the declared event.

FEMA Policy FP 104-010-04 Page 9 of 10 
5. Expanded Medical Facility: An expanded medical facility is part of the primary medical 

care facility and refers to an expansion of the primary medical care facility to increase its 

capacity when the primary medical care facility is overwhelmed by the declared event. 

6. Alternate Care Sites: Alternate Care Site is a type of Temporary Medical Facility and 

broadly describes any building or structure of opportunity converted for healthcare use. It 

provides additional healthcare capacity and capability for an affected community separate 

from a traditional, established healthcare institution, though healthcare institutions may 

partner with eligible Applicants operating an Alternate Care Site. 

7. Community-Based Testing Sites: Community-Based Testing Sites are strategically 

located sites within a community operated by a SLTT government for the purpose of 

providing COVID-19 testing to members of the community. 

8. Wraparound Services: Wraparound services in the context of this policy are the same as 

those defined in the Alternate Care Site Toolkit. The services will differ at each temporary 

medical facility. Such services include, but are not limited to, the following: linen and 

laundry services; food preparation and delivery; biomedical waste removal, including 

contaminated items such as personal protective equipment; perimeter fencing; contracted 

security guards; professional cleaning; and other related services. The toolkit and other 

Alternate Care Site resources are available on the HHS website at 

https://asprtracie.hhs.gov/technical-resources/111/covid-19-alternate-care-site-resources. 

MONITORING AND EVALUATION 

FEMA will closely monitor the implementation of this policy through close coordination with 

regional and field staff, as appropriate, as well as interagency partners and SLTT stakeholders. 

QUESTIONS 

Applicants should direct questions to their respective FEMA regional office. 

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