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COVID-19 Frequently Asked Questions (FAQs) for State Medicaid and CHIP Agencies
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Consolidated FAQs from CMS guiding state Medicaid and CHIP agencies on authorities, flexibilities, and operational actions during the COVID-19 public health emergency; affects state Medicaid/CHIP programs and relevant state agencies.
Policy Summary
Payercoloradoaccess
PolicyCOVID-19 Frequently Asked Questions (FAQs) for State Medicaid and CHIP Agencies
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 6, 2021
Last ReviewJan 6, 2021
Next Review DateJan 6, 2021
Key ActionStates must elect the optional COVID-19 testing eligibility group via a Medicaid Disaster Relief SPA to provide limited testing/diagnosis benefits to uninsured individuals during the PHE.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
8 setsoriginal CMS FAQ sets consolidated into one document
Jan 6, 2021last updated
Mar 18, 2020continuous coverage/enrollment requirement cutoff
Mar 18, 2020optional testing group effective
100%FMAP for testing group
Coverage criteria and operational flexibilities during the COVID-19 PHE
Optional COVID-19 testing eligibility group
Optional Medicaid eligibility group for uninsured individuals — limited to testing and related services during the PHE. Covered when ALL of the following are met:
State has elected the optional COVID-19 testing eligibility group via the Medicaid Disaster Relief SPA and submitted it to the state's CMS SPA mailbox (Medicaid Disaster Relief SPA template).
Election required to reimburse providers for testing/related services to individuals in this group.
The individual meets the statutory definition of 'uninsured individual' (section 1902(ss)) — not enrolled in a mandatory Medicaid group, not enrolled in most federal health programs (CHIP, Medicare, TRICARE, VA), and not covered by group health plan or group/individual health insurance (no exception if plan fails to cover testing).N/A
Coverage effective no earlier than March 18, 2020 and limited to services furnished during the public health emergency; benefits terminate at the end of the PHE.
No income or resource test applies for eligibility; individual must meet non-financial requirements including state residency and provision (or application for) a Social Security Number (state must assist applicants without an SSN).
Covered services are limited to in vitro diagnostic testing (and administration) and COVID-19 testing-related services furnished during a provider visit related to such testing; serological tests meeting FDA IVD definition are included.
For non-citizens or individuals without satisfactory immigration status, federal financial participation (FFP) is limited to emergency medical condition treatment services only (treatment coverage limited).
Eligibility, enrollment, and coverage flexibilities during PHE
States' enrollment, renewal, and signature flexibilities during the PHE. Apply the following rules:
States may use disaster-relief SPA mechanisms to extend or modify renewal/redetermination timelines (for MAGI-excepted groups states may elect 12-month renewals).
States may document and, when appropriate, seek CMS concurrence to process renewals or delays for cohorts rather than each individual case; concurrence notification may be via CMS state lead email and CMS may waive per-case documentation enforcement for defined cohorts.
Applicants and beneficiaries must still provide signed applications under penalty of perjury; electronic and telephonic signatures are acceptable — there is no blanket waiver of signature requirement.
States may enroll applicants based on self-attestation and perform post-enrollment verification (post-enrollment verification allowed); to claim FFCRA temporary FMAP increase, states must maintain benefits through the end of the month in which the PHE ends even if post-verification shows ineligibility (except residency).
Provider revalidation due dates paused during the PHE may be extended by the duration of the PHE plus six months for provider notification; states that paused revalidations must resume revalidation after the PHE ends and have up to six months after the PHE to cease payments to temporarily enrolled providers if enrollments not completed (1135 abbreviated enrollment conversion rule).
PHE coverage and premium criteria
Conditions and operational options states must follow to comply with FFCRA/CARES coverage and FMAP requirements:
States must exempt cost sharing for COVID-19 in vitro diagnostic tests and COVID-19 testing-related services (FFCRA Sec. 6004); if a state currently charges cost sharing for such services, it must submit a SPA to effectuate the exemption.
States must cover and exempt from cost sharing COVID-19 treatments described under FFCRA Sec. 6008(b)(4) (including FDA-approved, EUA-authorized, and EUA-authorized unapproved drugs and administration); states may operationalize exemptions via prior authorization, claim/diagnosis linkages, blanket exemptions, or other CMS-agreed systematic methodologies.
To claim the temporary 6.2 percentage point FMAP increase, states may not terminate coverage for beneficiaries enrolled on or after March 18, 2020 through the end of the month in which the PHE ends for reasons other than voluntary disenrollment or loss of state residency; states must also waive copays for testing and treatments for any quarter in which the increased FMAP is claimed.
States must maintain premium levels at or below amounts assessed on January 1, 2020; states that increased premiums after Jan 1, 2020 were given a 30-day grace period beginning March 18, 2020 to restore prior levels and reimburse affected beneficiaries to qualify for FMAP.
States seeking enhanced FMAP may not recoup payments or retroactively reduce eligibility for individuals whose Medicaid eligibility was maintained solely to comply with section 6008(b) of the FFCRA.
Medicaid/CHIP eligibility and administrative criteria related to COVID-19 federal benefits and hearings
Treatment of federal payments and related administrative guidance for eligibility determinations during the PHE:
Federal Pandemic Unemployment Compensation (FPUC) $600/week (monthly equivalent $2,580) must be disregarded for Medicaid and CHIP income determinations; enhanced matching for eligibility system improvements/maintenance may be available per applicable rules.
Lost Wages Assistance (Stafford Act) payments are excluded from income/resources for Medicaid and CHIP determinations; if a state adds the $100 weekly supplement, the full $400/week is excluded; if not, the $300 federal portion is excluded.
Pandemic Unemployment Assistance (PUA) is not automatically disregarded for MAGI methodologies; states may elect via SPA to disregard PUA for non-MAGI methodologies but cannot for MAGI-based determinations.
Recovery rebates (economic impact payments) are not income for Medicaid/CHIP eligibility and are excluded as a resource for 12 months for non-MAGI determinations.
States may not recoup medical assistance or retroactively terminate eligibility for periods maintained to comply with FFCRA section 6008(b); states must continue enrollment through the end of the month in which the PHE ends and follow termination procedures thereafter.
States should continue mailing hard copy notices (no evidence COVID-19 spreads via mail) unless beneficiary elects electronic notices; beneficiaries may change election or request mailed copies and states may post electronic versions as appropriate.
Fair hearings, reinstatement, and continuing coverage
Fair hearing and reinstatement flexibilities and obligations during the PHE:
States may hold fair hearings via video conference or telephone without additional CMS authority but must ensure accessibility and auxiliary aids; if an individual cannot participate due to lack of access, the state may not take final administrative action and may delay to accommodate an in-person hearing.
States must reinstate services discontinued due to a beneficiary's whereabouts being unknown if whereabouts become known prior to the next regular renewal; notice of reinstatement must be provided to beneficiaries.
States may reinstate coverage for beneficiaries who request a fair hearing more than 10 days after the date of action only if granted section 1135 authority specifying the reinstatement timeframe; states may request extension (example: align reinstatement to extended hearing window).
When claiming the temporary FMAP increase, states must continue coverage for beneficiaries enrolled on or after March 18, 2020 through the end of the month in which the PHE ends; states should suspend scheduled terminations and make good faith efforts to reinstate improper terminations.
Documentation and concurrence: For delays or suspensions of adverse actions, states should document delays in case records and seek CMS concurrence when implementing broad cohort exceptions; for certain flexibilities (video/telephone hearings and reinstatement for displaced beneficiaries) CMS concurrence is not required.
Presumptive eligibility (PE) and Hospital PE
Presumptive eligibility (PE) and Hospital PE (HPE) flexibilities during the PHE:
States may designate state agencies, counties, or local agencies as PE qualified entities to make PE determinations for MAGI-based groups by submitting a SPA; the Medicaid disaster relief SPA template may be used. (Note: state agencies cannot be designated to make PE determinations for non-MAGI groups except HPE per rules).
States may expand Hospital Presumptive Eligibility to additional eligibility groups (including institutional, age 65+, blindness/disability, medically needy, and demonstration populations) provided hospitals meet state qualification requirements and the state updates SPA as needed.
Transfer-of-asset rules do not apply during a PE period until a formal Medicaid application is submitted; states may elect whether to apply PETI rules during hospital PE and must provide hospitals guidance for income/deduction estimates if PETI applied.
States may change HPE performance standards during the PHE via the disaster relief SPA template but must maintain oversight and collect data on hospital performance.
Hospitals may process HPE applications by phone, secure online portals, or verbal/written screening tools if standardized processes are in place and hospitals collect required information; HPE determinations may apply to family/community members beyond patients.
Hospital PE can be used to expedite eligibility for disability-based applicants provided hospitals ask disability-focused questions sufficient to presumptively determine disability; PE coverage is not subject to continuous coverage protections under section 6008(b)(3).
Verification and post-enrollment verification
Verification and post-enrollment verification — permissible practices during the PHE:
States may modify verification policies to use attestation, adopt post-enrollment verification, or change reasonable compatibility standards by updating their verification plan or submitting a disaster relief addendum; CMS review not required prior to implementation for Medicaid (CHIP documents via disaster relief SPA).
States may enroll applicants based on self-attested information and complete required verification after enrollment (post-enrollment verification); when claiming enhanced FMAP states must continue benefits through the end of the month in which the PHE ends even if post-verification would show ineligibility (except for residency).
States may accept self-attestation for age, date of birth, state residency, household composition, and pregnancy (unless inconsistent info exists); financial data sources and AVS must be accessed and can be completed post-enrollment within a reasonable timeframe; citizenship/immigration may be provisionally accepted with a 90-day Reasonable Opportunity Period (ROP).
Resolving discrepancies: When electronic data conflicts with attestation, states may accept reasonable explanations from the individual or request documentation per 42 C.F.R. § 435.952(c)(2); if using the special circumstances exception due to inability to provide documentation, states must document reliance in the case record and may suspend periodic data matching with appropriate documentation.
Enrollment, verification, and continuity criteria
Enrollment, verification, and continuity — permissive state actions and mandatory obligations while claiming FFCRA temporary FMAP increase:
States may accept self-attestation for specified criteria and enroll based on attestation, completing verification post-enrollment; states must document verification policy changes in MAGI-based verification plans or internal policies for non-MAGI changes.
States must access required data sources for financial verification but may complete such verification after enrollment within a reasonable timeframe; CHIP may accept self-attestation or follow Medicaid processes for income verification.
When citizenship or immigration status cannot be promptly verified, states must provide benefits during a 90-day ROP while verification is completed; individuals remain enrolled during the ROP and states must follow ROP procedures.
To claim the temporary FMAP increase, states must maintain enrollment/coverage for beneficiaries enrolled on or after March 18, 2020 through the end of the month in which the PHE ends (exceptions: voluntary termination or loss of state residency) and suspend terminations when applicable.
Documentation: States must resolve electronic-attestation discrepancies per regulation, document reliance on attestation under special circumstances in case records, and update verification plans or use the MAGI-based Disaster Relief Verification Plan Addendum when making MAGI-based changes.
Coverage rules tied to FFCRA continuous enrollment condition
Coverage rules and required practices tied to receipt of the FFCRA temporary FMAP increase:
Maintain continuous enrollment (coverage) for all Medicaid beneficiaries enrolled on or after March 18, 2020 through the end of the month in which the emergency period ends; permitted terminations are only for voluntary disenrollment or loss of state residency.
States should make good faith efforts to identify and reinstate individuals terminated after March 18, 2020 for reasons other than voluntary termination or residency; reinstate coverage back to date of termination where feasible and suspend scheduled terminations during the emergency period.
States seeking enhanced FMAP must maintain individuals' participation in 1915(c) waivers and person-centered plans during the emergency period (prior to IFC effective date), reinstating individuals terminated after FFCRA enactment for failure to meet service rules; states should continue to apply assessed need and person-centered plan criteria when providing services.
Medicaid continuous enrollment and eligibility transition criteria
Protections for beneficiaries and rules for eligibility-group transitions when a state claims the FFCRA FMAP increase:
Medically needy individuals who attain eligibility via a spenddown must have Medicaid eligibility maintained through the last day of the month in which the PHE ends to qualify the state for the temporary FMAP increase.
States may not retroactively terminate eligibility or recoup payments for individuals whose eligibility was maintained under section 6008(b); enrollment and benefits continued for qualifying individuals cannot be reduced retroactively.
States that claim the FMAP increase may not increase patient liability or reduce personal needs allowances for institutionalized individuals enrolled as of March 18, 2020 (prior to IFC effective date); states must maintain same amount, duration, and scope of benefits or only transition to another group that provides equivalent benefits.
SSI-based beneficiaries who lose SSI may not be terminated from Medicaid prior to the end of the month in which the PHE ends if the state claims FMAP increase; states may transfer individuals only if the new group provides at least the same benefits.
Limitations post-IFC: Note that as of Nov 2, 2020 (IFC effective date), references to 'coverage' should be read as 'enrollment' and states may have limited ability to reduce amount/duration/scope consistent with 42 C.F.R. § 433.400; these FAQs reflect pre- and post-IFC distinctions where noted.
COVID-19 testing group coverage criteria
Eligibility and coverage criteria for the optional COVID-19 testing Medicaid eligibility group (summary):
Eligibility limited to individuals meeting the statutory definition of 'uninsured individual' under section 1902(ss) (excludes those enrolled in most federal programs or group health plans; short-term limited-duration insurance is not exclusionary).
Coverage effective no earlier than March 18, 2020 and limited to services related to testing and diagnosis of COVID-19 furnished during the emergency period; the limited benefit package terminates at the end of the PHE.
There is no income or resource test for the optional testing group; applicants must meet non-financial requirements such as state residency and SSN provision (state assists applicants without an SSN).
States must elect the group via the Medicaid Disaster Relief State Plan Amendment (SPA) template and submit to the state's CMS SPA mailbox to implement the optional testing group.
COVID-19 testing group coverage criteria
States electing the optional COVID-19 testing group must provide the limited testing/diagnostic benefit to uninsured individuals who meet non-financial criteria:
Covered services are limited to in vitro diagnostic tests (1905(a)(3)(B)) and administration, and COVID-19 testing-related services furnished during a provider visit related to testing; serological tests that meet FDA IVD definition must be covered.
Individuals enrolled in the optional testing group are not considered 'uninsured' if they are enrolled in group health plans or other federal health care programs; short-term limited-duration insurance does not preclude eligibility for the testing group.
States that elect the group may need to keep the group enrolled until the end of the month in which the PHE ends if seeking to satisfy FFCRA section 6008(b)(3) FMAP conditions, but the group's limited coverage itself terminates at the end of the PHE.
COVID-19 testing and related coverage criteria
Coverage and operational flexibilities for COVID-19 testing and related services during the PHE:
Tests for detection of SARS-CoV-2 and diagnosis of COVID-19 are mandatory Medicaid laboratory benefits (section 1905(a)(3)(B) and 42 C.F.R. § 440.30); states must cover in vitro diagnostic products and their administration during the PHE beginning March 18, 2020.
IFC flexibilities permit states to cover tests in non-office settings (e.g., parking lots) and self-collected home tests authorized by FDA when intended to avoid transmission; these flexibilities are retroactive to March 1, 2020 and apply during the PHE and any active surveillance period.
CHIP must cover in vitro diagnostic products for targeted low-income children and pregnant women from March 18, 2020 through the PHE, and no CHIP SPA is needed if lab/radiology already covered in CHIP state plan.
Home health agencies may collect diagnostic samples if ordered by a physician and within scope of practice, subject to face-to-face encounter timing requirements for first-time users; documentation and communication to ordering physician required.
COVERAGE CRITERIA — summary of coverage positions and criteria
Summary of core coverage positions and permissive flexibilities addressed in these FAQs:
FFCRA (as amended) requires Medicaid and CHIP to cover FDA-defined in vitro diagnostic SARS-CoV-2 tests and administration for the PHE beginning March 18, 2020; serological tests meeting FDA IVD definition must be covered though not recommended as sole basis for diagnosis.
X-rays are not IVDs but remain mandatory Medicaid services when medically necessary and may be part of COVID-19 testing-related services when indicated.
States have broad flexibility to cover and reimburse telehealth (including teledentistry) using various communication methods; no federal approval is required to reimburse at the same rate as face-to-face but a SPA is required to change payment methodology or set different rates.
EPSDT medically necessary services for children must continue and can be delivered via telehealth; early intervention and other assessments may be conducted via telehealth if permitted and states may reimburse accordingly.
Coverage stances and permissible state flexibilities during PHE
Permissible state flexibilities and program-specific coverage positions during the COVID-19 PHE:
States may cover well-child visits via telehealth under EPSDT and may set the same or different payment rates; SPA required if establishing a new payment methodology for telehealth rates.
States may continue provision of Home and Community-Based Services (HCBS) to individuals in acute care hospitals under section 3715 of the CARES Act; services must be in person-centered plans and not substitute hospital obligations.
HCBS assessment timing: States may seek section 1135 waiver authority to delay initial and annual level-of-care determinations and assessments for HCBS programs (up to one year postponement) where applicable, using 1135(b)(5) parameters and Appendix K where required.
Appendix K approvals expire one year from effective date and cannot extend beyond one year from March 31, 2021; states can fund tablets/phones as Assistive Technology under 1915(c) via Appendix K but not general-utility phone minutes/cards.
States may temporarily relax prior authorization for medications and supplies for medically fragile populations; SPA may be required for changes to quantity dispensed, and states must cover COVID-19 testing/treatments (including EUA drugs) to claim enhanced FMAP.
MFP programs may implement programmatic changes (telephone/video transition activities) without prior CMS approval for allowable changes but should notify their MFP Project Officer; MFP grantees may request expedited review to use grant funds for PPE and can transfer up to 10% between budget line items for participant-related activities.
MFP COVID-19 coverage criteria and restrictions
Conditions and restrictions for use of MFP grant funds and supplemental demonstration services during the PHE:
MFP grantees may use grant funds for supplies and equipment (including PPE) that directly support MFP participants; CMS will provide expedited review for such requests and grantees should notify their MFP Project Officer.
Budget transfers up to 10% between MFP grant line items are permitted for activities that directly support MFP participants; grantees must follow grant terms and submit supplemental budget justifications when required.
Supplemental demonstration services funded by MFP are only available to eligible MFP participants and for the participant's 365-day enrollment period; MFP funds cannot be used after the 365-day period ends.
Statutory MFP eligibility requirements (e.g., minimum 90-day institutional stay) and other statutory constraints remain in effect and cannot be modified by these flexibilities.
PPE
PPE coverage criteria and mechanisms:
States may cover PPE for Medicaid beneficiaries if determined medically necessary under the home health medical supplies, equipment, and appliances benefit (42 C.F.R. § 440.70(b)(3)); states may apply reasonable limits on amount, duration, and scope consistent with the benefit's purpose.
States can fund PPE for beneficiaries or unpaid caregivers via section 1915(c) Appendix K by adding a service (e.g., Extended State Plan Services: Medical Supplies) when PPE is used to deliver care to the individual.
NEMT
NEMT coverage and provider rules during the PHE:
Provider enrollment and screening remain conditions of payment; there is no categorical waiver of provider enrollment requirements. Any abbreviated enrollment under an approved section 1135 waiver is temporary and must be converted to full enrollment or deactivated within 6 months after the PHE is lifted.
States retain responsibility to determine the least costly and most appropriate vehicle for the beneficiary and may authorize non-emergency ambulance transport when it is the least costly and most appropriate option given circumstances (e.g., infection control for COVID-19 patients).
Meal delivery and NEMT: Under certain authorities (1915(c), 1915(i)), states may cover delivery of meals to specific beneficiaries and may include NEMT providers as qualified providers; rates may include components for meal and transport services as applicable.
Broker exceptions: Brokers are generally prohibited from providing trips, but four regulatory exceptions exist (rural area with no other provider, highly specialized transport, insufficient availability, or government broker conditions); states may use disaster SPA to implement exceptions during emergency.
HRSA and Medicaid coordination
Coordination between HRSA's uninsured reimbursement program and Medicaid for testing and treatment:
To reimburse providers for testing services to uninsured individuals under the optional COVID-19 testing group, a state must elect the group under its state plan; providers can be reimbursed by Medicaid when the state has determined eligibility and enrolled the individual in the testing group.
HRSA's COVID-19 Claims Reimbursement program provides direct reimbursement to enrolled providers for testing and treatment of uninsured individuals (claims allowed for services on or after Feb 4, 2020); providers must enroll in HRSA program to access funds.
HRSA (via its contractor) will perform third-party clears and retrospective reviews; if HRSA paid a claim but the individual was later found Medicaid-enrolled for the service date, HRSA will recover payment and advise the provider to bill Medicaid (Medicaid is payer of last resort).
Providers may submit HRSA claims for treatment services for individuals in the optional testing group if those individuals lack coverage for treatment services; testing services for Medicaid-enrolled individuals are not eligible for HRSA reimbursement.
Administrative claiming / RMTS
Administrative claiming and RMTS guidance during the PHE:
States may claim Medicaid administrative match for COVID-19-related administrative activities if costs are allocable and allocation methodologies meet requirements; amendments to cost allocation plans may be needed and CMS will assist expediently.
Administrative costs resulting from COVID-19 initiatives are not eligible for the 6.2 percentage point FFCRA FMAP increase.
For RMTS, sampled school staff working remotely may respond to sampled moments indicating their activity for the sampled date/time; sampled individuals not working should be coded as paid time not working if salaried or unpaid time if furloughed, and paid time not working moments reallocated across activity codes. During the PHE, CMS will not ask states to impose individual district penalties for failing to reach 85% RMTS participation.
Interim and Retainer Payment Criteria
Interim and retainer payment SPA requirements and guardrails — states may implement only when SPA specifies the terms and reconciliation process:
State must submit a SPA that specifies provider qualifications to receive interim payments, the methodology for computing interim payments (e.g., prior claims experience or state plan rates), the service period interval represented by each interim payment, the duration of interim payments, and the timeframe for reconciliation to actual claims.
Interim payments represent payment for services furnished during the interim period and must be reconciled to actual claims; any interim payments in excess of claims are provider overpayments and the federal share must be returned to CMS in accordance with 42 C.F.R. Part 433, Subpart F; routine claim payments must not be made concurrently (no duplicate payments).
Retainer payments may be authorized consistent with SPA/1115 authority constraints: amounts should not exceed payment for the relevant service, may be set as a percentage of current rate, and retainer episodes are limited (up to three 30-day episodes per individual during the disaster period; single episode limited to the lesser of 30 consecutive days or bed-hold days).
States should include guardrails in interim/retainer payment SPAs, including provider attestations (e.g., maintain staffing/wages, disclose receipt of other funds), requirements to continue furnishing services and maintain access to care, and recoupment procedures for inappropriate or duplicate payments.
Managed care retainer payments: To require managed care plans to make retainer payments, states must obtain approval under 42 C.F.R. § 438.6(c) for state-directed payments and submit a state-directed payment preprint after authorizing retainer payments under Medicaid authority.
Administrative costs related to COVID-19 initiatives are not eligible for the 6.2 percentage point FMAP increase; states must ensure interim payment SPAs describe return of federal share for overpayments and reconciliation reporting (CMS-64 prior period adjustments).
Provider enrollment, billing, and operational actions
Documentation Required
Six-month deadline to convert temporary enrollments after PHE
States that received section 1135 waiver approval allowing temporary abbreviated provider enrollment have up to six months from the end of the PHE (including extensions) to cease payment to providers not fully screened and enrolled; states must complete enrollments or cease payment and CMS may require assurances and corrective action reporting.
Documentation Required
Resume revalidations and apply PHE + 6 months lead time
States that paused provider revalidations per 1135 waiver must resume revalidation after the PHE ends; revalidation due dates that occurred during the PHE may be delayed by the PHE duration plus six months to provide lead time for provider notification.
Documentation Required
Temporary abbreviated enrollment and revalidation flexibilities
Under approved section 1135 waivers, states may perform abbreviated enrollments and pause revalidations during the PHE, but must convert temporary enrollments to full enrollment or deactivate them within six months after the PHE ends; revalidation timelines paused during the PHE may be extended by the PHE duration plus six months.
Prior Authorization
Prior authorization option to operationalize COVID-19 treatment cost-sharing exemption
States may require prior authorization to link use of COVID-19 treatments (FDA-approved, EUA-authorized, or unapproved under EUA) to a confirmed or suspected COVID-19 diagnosis to operationalize cost-sharing exemptions, or use other CMS-agreed systematic methodologies.
- PA can be used to tie drugs/biologics to COVID-19 diagnosis when cost-sharing exemption is claimed
- States may exempt broadly or establish CMS-agreed alternative methodologies
Documentation Required
Fair hearing flexibilities during the PHE
States may suspend certain adverse actions, delay scheduling fair hearings, hold hearings via video/telephone, and reinstate services if a beneficiary was displaced; states should seek CMS concurrence for some flexibilities but video/telephone hearings and reinstating services after displacement may be implemented without concurrence.
- Suspend adverse actions where notice not sent or likely not received
- Delay scheduling/decisions under 42 C.F.R. §431.244(f)(4)(i)(B)
- Hold hearings via video/telephone while ensuring accessibility and auxiliary aids
- Reinstate services when beneficiary whereabouts become known
Documentation Required
Request 1135 authority to extend fair hearing request period beyond 90 days
States may request section 1135 waiver authority to allow beneficiaries more than 90 days to request a fair hearing; the statutory maximum timeframe is 90 days unless extended via 1135 waiver.
Documentation Required
Remote fair hearings: accessibility and participation protections
States can hold fair hearings via video conference or telephone without additional CMS authority but must ensure accessibility and auxiliary aids; if a member cannot participate due to lack of access, the state may not take final administrative action and must delay to accommodate participation.
- Provide auxiliary aids/services at no charge on request
- Delay final action if beneficiary cannot fully participate remotely
Prior Authorization
Use section 1135 to permit reinstatement beyond 10 days
States seeking to reinstate coverage for beneficiaries who request a fair hearing more than 10 days after the date of action must obtain section 1135 authority specifying the reinstatement period (e.g., align reinstatement window with extended hearing request timeframe).
Denial Risk
Do not terminate eligible beneficiaries through end of PHE month (FMAP condition)
To qualify for the temporary FMAP increase, states may not terminate individuals determined eligible through the end of the month in which the PHE ends; termination during that period would jeopardize FMAP eligibility.
- Exceptions to termination: voluntary disenrollment or loss of state residency
- States should make good faith efforts to identify and reinstate terminations after March 18, 2020
Prior Authorization
Continuous coverage requirement and reinstatement obligations
States must not terminate coverage for beneficiaries enrolled on or after March 18, 2020 (except for voluntary termination or loss of state residency); states should reinstate those terminated for non-residency reasons and suspend scheduled terminations during the emergency period.
- Coverage should be reinstated back to the date of termination
- States expected to inform and encourage reenrollment for those terminated after March 18, 2020
Prior Authorization
Incarceration: enrollment treatment and FMAP limits
Incarceration does not by itself change Medicaid eligibility; states may suspend or terminate eligibility consistent with FFP limitations for inmates, but must ensure re-enrollment for inpatient services to claim FMAP if needed and continuous coverage protections still apply through the month the PHE ends.
- FFP for inmates limited to covered inpatient services
- States can suspend rather than terminate and re-enroll if admitted to inpatient facility
Documentation Required
Elect the COVID-19 testing group via Disaster Relief SPA
States must elect the optional COVID-19 testing eligibility group by completing the Medicaid Disaster Relief SPA template and submitting it to the state's CMS SPA mailbox to provide limited testing/diagnosis benefits to uninsured individuals.
Billing Rule
COVID-19 testing group limited to testing and testing-related services
Coverage for the COVID-19 testing group is limited to in vitro diagnostic testing and COVID-19 testing-related services furnished during a provider visit related to such testing during the PHE; the benefit package is explicitly constrained to testing/diagnosis services.
Billing Rule
100% FMAP for COVID-19 testing group services
The FMAP for services provided to individuals enrolled in the COVID-19 testing group is 100% for testing and testing-related services and related administrative expenditures; the 100% match applies only to beneficiaries enrolled in the testing group.
Documentation Required
Mandatory coverage of COVID-19 IVDs and flexibilities for testing locations
Medicaid coverage must include in vitro diagnostic products for detection of SARS-CoV-2 and administration as a mandatory laboratory benefit, and states may cover tests in non-office settings and self-collected home tests during the PHE under IFC flexibilities intended to avoid transmission.
- IFC flexibilities permit testing in parking lots and FDA-authorized home self-collection processing
- Flexibilities effective retroactive to March 1, 2020
Documentation Required
Home health agencies may collect COVID-19 samples if ordered and within scope
Home health agencies may collect diagnostic samples for COVID-19 if ordered by a physician and within the scope of practice under state law; face-to-face encounter timing requirements apply for first-time users per 42 C.F.R. §440.70(f).
- If first use of home health, face-to-face encounter must be within 90 days before or 30 days after start of services
- Ordering physician must document encounter timing and practitioner
Billing Rule
Telehealth reimbursement allowed at same rates; SPA needed for new methodologies
States can reimburse providers for telehealth in the same manner or at the same rate as face-to-face services without federal approval; a State Plan Amendment is required only if the state establishes a different payment methodology or different rates for telehealth.
- No SPA needed to reimburse at same rate as face-to-face
- SPA required to describe and approve new payment methodology if rates differ
Denial Risk
Medicaid coordination when third-party denies telehealth claims
If a third-party payer (Medicare or commercial) denies a claim for substantive reasons and the service is covered under the Medicaid state plan, Medicaid may review and pay according to the state plan and pursue recovery or coordination of benefits if the third party later becomes liable.
- Medicaid is payer of last resort; states should pursue COB/TPL when appropriate
- Medicaid may recover HRSA or other payments if payer liability is later established
Documentation Required
Permitted telehealth for home health face-to-face encounter initiation
Face-to-face encounters required for initiation of home health services may be conducted via telehealth by authorized practitioners, with required documentation of clinical findings and communication to the ordering physician.
- Allowed practitioners include physicians, NPs, CNS, CNMs, PAs, and attending acute/post-acute physicians
- Clinical findings must be incorporated into the beneficiary's medical record
Prior Authorization
Temporary PA flexibilities for medications and supplies
States may temporarily suspend or relax prior authorization requirements for medications and supplies for medically fragile populations; states set PA processes for FFS and managed care and may need a SPA for changes to quantity dispensed.
- States determine PA processes for both FFS and managed care
- SPA may be required for changes to dispensing quantities or payment methodologies
Billing Rule
Telehealth payment policy for pediatric well-child visits (SPA required for new rates)
States may set payment rates for pediatric well-child visits delivered via telehealth; if a state establishes a different payment methodology or rates for telehealth, a state plan amendment is required to describe and obtain approval for the new methodology.
Documentation Required
MFP operational protocol flexibilities — implement and notify
MFP programs may implement temporary programmatic changes (e.g., telephonic or video transition activities) without prior CMS approval if directly related to COVID-19 response, but grantees should notify their MFP Project Officer as soon as possible.
- Notify MFP Project Officer for programmatic changes
- Follow applicable 1915(c) or other Medicaid waiver processes if changes affect HCBS waivers
Prior Authorization
Submit section 1135 waiver email to permit clinic telehealth when neither party onsite
To request time-limited section 1135 modification to permit clinic services (42 C.F.R. §440.90) to be provided via telehealth when neither patient nor practitioner is onsite, states should submit an 1135 waiver request via email to their State Lead and Jackie.Glaze@cms.hhs.gov.
Billing Rule
Allowable MFP budget transfers up to 10% for COVID-19 response
MFP grantees may transfer up to 10% of MFP grant funds between budget line items for activities that directly support MFP participants, subject to grant terms and any required supplemental documentation or approvals.
- Transfers must align with program goals and grant terms
- Contact Grants Management Officer for technical assistance and approvals
Documentation Required
Convert or deactivate abbreviated 1135 enrollments within 6 months after PHE
Abbreviated provider enrollment authorized under an approved section 1135 waiver is temporary and must be converted to full enrollment or deactivated within six months after the PHE is lifted.
Prior Authorization
Permit NEMT ambulance transport when least costly/appropriate given COVID-19 circumstances
States may determine that non-emergency ambulance is the least costly and most appropriate mode of transportation in specific circumstances (e.g., infection control for COVID-19 patients) and authorize ambulance transport accordingly.
- State must still ensure NEMT provision meets requirement to provide necessary transportation
- Determination can consider infection control needs and availability of other options
Prior Authorization
Submit SPA to request interim payment methodology with reconciliation
States may submit a Medicaid Disaster Relief SPA to establish interim payment methodologies that provide periodic interim payments to providers during the PHE, specifying qualifications, computation methodology, reconciliation process, and duration; CMS will consider such SPAs on an expedited basis.
- Interim payments must be reconciled to actual claims and federal share of overpayments returned per regulations
- SPA must describe how interim payments are computed (e.g., prior claims experience)
Documentation Required
State-directed retainer payments via managed care require 42 C.F.R. §438.6(c) approval
If states require managed care plans to make retainer payments to providers, they must obtain approval under 42 C.F.R. § 438.6(c) for state-directed payments and submit a state-directed payment preprint after authorizing retainer payments under appropriate Medicaid authority.
- Retainer payments must be authorized under 1915(c), 1115(a), or other Medicaid authority before seeking 438.6(c) approval
- Follow CMS guidance and preprint submission process
Billing Rule
Prohibition on duplicate payments during interim payment period
Interim payments become the state plan payment during the interim period and states must not make routine claim-based payments concurrently; duplicate payments (interim plus claim payment) are not permitted.
- States must reconcile interim payments to billed claims and return federal share of overpayments
- Retainer payments are distinct from interim payments and serve different purposes
Coding, code groups, and quick reference values
Statutory authorities for COVID-19 testing groupmixed
| 1902(a)(10)(A)(ii)(XXIII) | Permits optional Medicaid eligibility group for COVID-19 testing |
| 1902(ss) | Statutory provision related to the optional COVID-19 testing eligibility group |
COVID-19 testing and diagnosticsmixedCovered
| In vitro diagnostic products and COVID-19 testing-related services exempt from Medicaid/CHIP cost sharing under FFCRA Section 6004 (includes administration) |
Operational guidance (no billing codes)mixed
| No specific CPT/HCPCS/ICD-10 codes referenced; policy-level guidance on presumptive eligibility and hospital PE operational flexibilities |
Cost sharing restrictionmixed
| No codes listed |
COVID-19 testing group benefitsmixed
| Limited benefit package for testing and diagnosis of COVID-19 for uninsured individuals under the optional testing group (no specific CPT/HCPCS codes listed) |
COVID-19 diagnostic and serological testingmixedCovered
| In vitro diagnostic testing including serological tests for COVID-19 as defined by 21 C.F.R. 809.3(a); states electing the testing group must provide coverage |
COVID-19 testing coveragemixedCovered
| COVID-19 in vitro diagnostic products and administration covered as a mandatory laboratory benefit under section 1905(a)(3)(B) and 42 C.F.R. § 440.30 |
Teledentistry coding guidanceHCPCS | mixed
| No codes listed |
Pharmacy/Drug coverage coding considerationsmixed
| Guidance references state plan/SPA considerations for pharmacy quantity changes and coverage of EUA drugs; no specific billing codes provided in this excerpt |
PPE coverage via state plan authoritymixed
| States may cover PPE for Medicaid beneficiaries if medically necessary under home health medical supplies/equipment benefit (42 C.F.R. 440.70(b)(3)) or via 1915(c) Appendix K additions |
HRSA reimbursementmixed
| HRSA COVID-19 Claims Reimbursement program provides direct reimbursement for testing and treatment of uninsured individuals; providers must enroll in HRSA program to receive payment |
Regulatory references for interim payment reconciliationmixed
| 42 C.F.R. Part 433 Subpart F | Requirement to return federal share of provider overpayments from interim payments |
| 45 C.F.R. Part 95 Subpart A | Time limits and claiming requirements applicable to prior period adjustments and reconciliation (referenced for SPA interim payment reconciliations) |
Appendix K dates
Appendix K earliest effective dateJanuary 27, 2020
Appendix K approval expirationApprovals expire one year from the effective date (cannot extend beyond one year from March 31, 2021)
Appendix K retroactive useMay be approved retroactively to the date of the event as needed
Reinstatement request window (example)
Example reinstatement alignmentStates may request section 1135 authority to align reinstatement period with extended hearing request windows (example: allow reinstatement up to 110 days after date of action to match a 120-day hearing request window)
Reinstatement beyond 10 days requires 1135To reinstate coverage for hearings requested more than 10 days after action, state must obtain section 1135 authority specifying reinstatement period
Specify days in 1135 requestSection 1135 waiver request should specify the number of days following the effective date of an adverse action during which the state will reinstate services
Medically needy spenddown maintenance
Medically needy spenddown maintenanceEligibility maintained through the last day of the month in which the public health emergency ends for individuals who attained eligibility via spenddown
Applies for FMAP eligibilityMaintaining spenddown eligibility through PHE end is required for states seeking the temporary 6.2 percentage point FMAP increase
Coverage continuity despite budget periodThis applies even if the individual's budget period ends before the month the PHE ends and they would not meet spenddown in the new period
Income/resource test for COVID-19 testing group
Income/resource test for testing groupNone — no income or resource test required for eligibility in the COVID-19 testing group
Other non-financial requirementsMust be a state resident and furnish a Social Security Number (state must assist applicants without an SSN to apply)
FFP limits for non-citizensFor those lacking satisfactory immigration status, FFP limited to emergency medical condition treatment services only
Effective date floor
Effective date floorCoverage effective no earlier than March 18, 2020
IFC retroactivity for testing flexibilitiesCertain testing flexibilities under the IFC are retroactive to March 1, 2020
State election timingStates elect the optional testing group via Medicaid Disaster Relief SPA; coverage for group services may be effective on or after March 18, 2020
MFP internal budget transfer cap
MFP internal budget transfer capUp to 10% of MFP grant funds may be transferred between budget line items for activities directly supporting MFP participants
Justification and complianceTransfers must align with grant terms, be justified, and follow supplemental budget submission processes where required
Consult Grants Management OfficerGrantees should contact the Grants Management Officer for approvals and technical assistance
MFP enrollment coverage period
MFP enrollment coverage periodQualified MFP demonstration services may be provided during the participant's 365-day enrollment period
Services end after 365 daysMFP demonstration services are not required to continue after the participant's 365-day enrollment period ends
Document in Operational ProtocolMFP demonstration services must be documented in the state's approved Operational Protocol
Temporary enrollment conversion period
Temporary enrollment conversion periodAbbreviated provider enrollments under an approved section 1135 waiver must be converted to full enrollment or deactivated within 6 months after the PHE is lifted
Abbreviated enrollments are temporarySection 1135 abbreviated enrollment is a temporary streamlining measure and cannot be permanent
Provider obligationsProviders must be fully screened and appropriately licensed for full enrollment conversion
RMTS district participation threshold
RMTS district participation threshold85% RMTS participation threshold referenced; CMS will not ask states to impose individual district penalties for not reaching 85% during the PHE
Coding for non-working sampled staffSampled moments for staff not working should be coded as paid time not working if salaried or unpaid time if furloughed; reallocate paid time not working across other activity codes
Allocation methodology updatesStates may need to amend cost allocation plans and CMS will work with states expeditiously to update methodologies for COVID-19 activities
Retainer payment episode limits
Retainer payment episode limitsUp to three 30-day episodes of retainer payments per individual during the disaster period; a single episode limited to the lesser of 30 consecutive days or applicable bed‑hold days
State plan description requiredStates must describe circumstances and limits on duration/number of episodes in the applicable SPA or Appendix K
Rate setting and guardrailsStates can set retainer rate at a percentage below full rate and should include guardrails (attestations, recoupment, no layoffs) in SPA submissions
Key definitions and terms used in these FAQs
Emergency period described in FFCRA sections 6004 and 6008
Emergency period definitionThe emergency period is the duration of the public health emergency declared under section 319 of the Public Health Service Act for COVID-19, effective January 27, 2020 (per 1135(g)(1)(B))
Emergency period renewalsThe emergency period continues through any renewal of the HHS Secretary's public health emergency declaration and expires after 90 days unless extended
CMS notification at terminationCMS will inform states when the public health emergency period for COVID-19 ends
Appendix K (1915(c) waiver appendix)
Appendix K purposeAppendix K is the 1915(c) waiver application appendix for use during emergencies to describe temporary changes to HCBS waivers
Appendix K effective/expiration notesAppendix K approvals may be retroactive to the event date and expire one year from the effective date; end dates cannot extend beyond one year from March 31, 2021
Appendix K allowable changesMay add services, expand provider qualifications, permit payment when individual is in short-term institutional stay, and other waiver flexibilities as described
Blanket waivers (section 1135)
Section 1135 blanket waiversMedicare blanket waivers issued under section 1135 can temporarily modify or waive certain Medicare, Medicaid, CHIP, or HIPAA requirements applicable to providers/suppliers during an emergency
State law limitationsMedicare blanket waivers do not waive state law; absent state waiver activity, providers remain subject to state requirements
Types of 1135 waiversDifferent kinds of 1135 waivers exist (including Medicare blanket waivers); HHS Secretary may issue blanket waivers to help beneficiaries access care
Timeliness standard exception
Timeliness standard exceptionStates may be excused from meeting federal timeliness standards for processing applications and renewals during administrative emergencies; must document delays in individual case records
Broad cohort concurrenceFor broader cohorts, states are advised to obtain CMS concurrence and document the exception; CHIP should use a disaster relief SPA
No SPA required for case-by-case exceptionA Medicaid SPA is not required to exercise timeliness standard exception on a case-by-case basis
COVID-19 testing-related services (definition)
COVID-19 testing-related services definitionIncludes any in vitro diagnostic product described in section 1905(a)(3)(B) and other COVID-19 testing-related services for which payment may be made under the State plan; does not include services for treatment of COVID-19
States must submit SPA to remove cost sharingStates that currently charge cost sharing for these services must submit a SPA (Medicaid Disaster Relief SPA template for Medicaid)
Testing-related services may include X-ray as componentX-rays are not IVDs but can be part of COVID-19 testing-related services when medically necessary
community spouse
Community spouse definition referenceCommunity spouse is defined in section 1924(h)(2) of the Social Security Act as the spouse of an institutionalized spouse (used in context of income calculations)
FPUC exclusion for community spouse incomeFederal pandemic unemployment compensation is excluded when determining income available to community spouse for maintenance allowance
Context of useTerm appears in guidance related to treatment of federal pandemic unemployment compensation for Medicaid eligibility calculations
qualified entity
Qualified entity (PE) definitionA qualified entity is an entity determined by the state to be capable of making presumptive eligibility determinations for MAGI-based groups; state agency, county, or local agency may be designated
SPA required to elect qualified entityTo elect a qualified entity, the state must submit a SPA indicating the eligibility groups for PE determinations
Qualified entity limitationsA state agency cannot be designated to make PE determinations for non-MAGI groups via this mechanism
hospital presumptive eligibility
Hospital presumptive eligibility (HPE)HPE permits hospitals to make PE determinations for specified groups; states may expand HPE to additional groups provided hospitals meet state qualifications
Groups eligible for HPE expansionStates may add groups including age 65+, blindness/disability, medically needy, and certain demonstration populations to HPE
State oversightParticipating hospitals must meet state qualification requirements and comply with procedures/standards established by the state
post-enrollment verification / ROP
Post-enrollment verification / ROPStates may enroll applicants based on self-attested information and complete verification post-enrollment; citizenship/immigration may be verified during a 90-day reasonable opportunity period
Attestable criteriaStates can accept self-attestation for age, state residency, household composition, and pregnancy (unless inconsistent information exists)
Financial verification timingStates must access certain data sources to verify financial eligibility but may do so within a reasonable period after enrollment
post-enrollment verification
Post-enrollment verificationVerification processes a state elects to complete after furnishing benefits based initially on self-attested information; must follow verification plan addendum if used
Documentation requirementStates using post-enrollment verification to claim enhanced FMAP must continue benefits through end of month PHE ends even if verification later shows ineligibility (except residency)
CHIP flexibilityFor CHIP, states may accept self-attestation of income or follow Medicaid verification policies per 42 C.F.R. § 457.380(d)
reasonable opportunity period (ROP)
Reasonable Opportunity Period (ROP)A 90-day period during which states must provide benefits while citizenship or satisfactory immigration status is being verified if not promptly verifiable electronically
Benefits during ROPStates must furnish benefits during the 90-day ROP based on declaration of citizenship/satisfactory immigration status if other eligibility criteria met
Verification follow-upStates should complete verification within the ROP and may terminate at ROP end if eligibility not confirmed (subject to continuous coverage rules)
continuous enrollment
Continuous enrollment requirementTo receive the temporary FMAP increase, states must provide continuous coverage/enrollment through the end of the month in which the emergency period ends for beneficiaries enrolled on or after March 18, 2020
Allowed terminationsExceptions: voluntary disenrollment and loss of state residency; deceased individuals may be terminated
Reinstatement expectationStates should make good faith efforts to identify and reinstate individuals terminated after March 18, 2020 for reasons other than voluntary termination or non-residency
continuous coverage / enrollment
Continuous coverage / enrollmentStates must not terminate coverage for beneficiaries enrolled on or after March 18, 2020 through the end of the month in which the PHE ends to qualify for increased FMAP
Coverage vs. enrollment terminologyPost-Nov 2, 2020 IFC, references to 'coverage' should be read as 'enrollment' and applied to 'validly enrolled' beneficiaries per §433.400(a)
Suspend scheduled terminationsStates should suspend scheduled terminations during the emergency period and reinstate coverage back to date of termination where feasible
presumptive eligibility (definition)
Presumptive eligibility definitionIndividuals determined presumptively eligible are not considered 'enrolled' under the state plan and thus are not subject to continuous coverage protections
PE not enrolled under state planPE recipients have not received a formal eligibility determination under the state plan
Implication for FMAPBecause presumptively eligible individuals are not 'enrolled,' continuous coverage FMAP conditions do not apply to them
reinstatement (definition)
Reinstatement definitionStates should make good faith efforts to identify and reinstate individuals terminated after March 18, 2020 for reasons other than voluntary termination or non-residency; coverage should be reinstated back to the date of termination
Encouraged actionsStates expected to inform and encourage contact for reenrollment and, where feasible, automatically reinstate terminated individuals
Suspend scheduled terminationsStates should suspend terminations scheduled during the emergency period
COVID-19 testing group (definition)
COVID-19 testing group definitionNew optional Medicaid eligibility group for uninsured individuals to receive limited testing/diagnostic services during the COVID-19 PHE
Statutory citationAdded at section 1902(a)(10)(A)(ii)(XXIII) of the Social Security Act
Election via SPAStates must elect this optional group via the Medicaid Disaster Relief SPA to provide the limited benefit package
Uninsured individual (for testing group)
Uninsured individual (testing group)Person not eligible for mandatory Medicaid groups, not enrolled in Medicaid (with limited-benefit exceptions), not enrolled in federal health programs, and not covered by group health plans or qualified health plans (per section 1902(ss))
Short-term limited-duration insurance exceptionIndividuals enrolled in short-term, limited-duration insurance are eligible for the testing group because such plans are excluded from the PHSA definition of Individual Health Insurance Coverage
No exception for plans not covering testingEnrollment in a group plan that does not cover COVID-19 testing does not make an individual eligible for the testing group
Uninsured individual (statutory reference)
Uninsured individual (statutory reference)Defined in section 1902(ss) of the Act; excludes those enrolled in CHIP, Medicare, TRICARE, VA, federal employee plans, and group health plans as defined in PHSA §2791
Limited-benefit Medicaid exceptionsEnrollment in certain limited-benefit Medicaid groups (e.g., family planning, TB, medically needy limited coverage) does not preclude meeting the 'uninsured' definition
Pregnant women nuanceCertain pregnant women covered under specific optional groups may be excluded per CARES Act amendment—states should seek technical assistance if needed
In vitro diagnostic testing / serological tests (definition)
In vitro diagnostic testing / serological tests (definition)IVDs are defined at 21 C.F.R. § 809.3(a); serological tests for COVID-19 meet the FDA definition of IVDs and states must provide coverage for them under the testing group
IVD componentsIncludes reagents, instruments, and systems intended for diagnosis and use in collection/preparation/examination of specimens from the human body
Serology diagnostic cautionFDA advises serological tests should not be used as the sole basis for diagnosis
COVID-19 diagnostic tests (definition)
COVID-19 diagnostic tests definitionIn vitro diagnostic products for detection of SARS-CoV-2 or diagnosis of COVID-19, covered as mandatory laboratory benefit under 1905(a)(3)(B)
Coverage settings flexibilityIFC permits coverage for tests in non-office settings and self-collected home tests if intended to avoid transmission (retroactive to March 1, 2020)
Mandatory lab benefitTests for detection of SARS-CoV-2 are a mandatory laboratory service under Medicaid statutory provisions
FFCRA 6008(b) termination dates
FFCRA 6008(b) termination datesVarious FFCRA 6008(b) provisions terminate at specified times: some expire the first day of the month following the end of the calendar quarter in which the PHE ends; others expire the first day of the month following the month in which the PHE ends
Cost-sharing exemption through quarter endStates must maintain cost-sharing exemption for testing/treatment through the last day of any quarter in which they claim the increased FMAP
State attestation for FMAP drawsBy drawing increased FMAP funds, states attest they met conditions and that claimed expenditures qualify
In vitro diagnostic product (IVD)
In vitro diagnostic product (IVD)IVDs are reagents, instruments, and systems intended for diagnosis and for use in collection/preparation/examination of specimens from the human body (21 C.F.R. § 809.3(a))
X-rays not IVDsX-rays are not IVDs under the regulation though may be part of testing-related services when medically necessary
FDA cross-referenceSection 1905(a)(3)(B) defines IVDs by cross-reference to FDA regulations at 21 C.F.R. § 809.3(a)
Serological test (COVID-19)
Serological test (COVID-19)Serological tests detect antibodies to SARS-CoV-2 and meet the FDA definition of IVDs; states that elect the testing group must provide coverage for serology tests
Diagnostic role cautionFDA advises serological tests should not be used as the sole basis for diagnosis
EUA authorizationsFDA has issued EUAs for certain serological tests used by clinical laboratories
Telehealth/Teledentistry
Telehealth/TeledentistryTelehealth includes telephonic and video technologies; states have broad flexibility to cover telehealth and may reimburse at same or different rates (SPA needed for payment methodology changes)
Home health telehealth visits and EVVRemote delivery of home health/personal care via telehealth is not an 'in-home visit' for EVV purposes, though states may elect to apply EVV
EPSDT and telehealthEPSDT medically necessary services for children may continue and be delivered via telehealth where appropriate; well-child visits coverable via telehealth
Appendix K (additional refs)
Appendix K (additional refs)Appendix K is the mechanism to request emergency changes to 1915(c) waivers; approvals expire one year from effective date and cannot extend beyond one year from March 31, 2021
Appendix K use casesStates may use Appendix K to add services, expand provider pools, fund devices to enable remote service delivery, and indicate service expansions for PHE
Submission guidanceA completed Appendix K should be submitted for each affected waiver and CMS will work with states to determine allowable changes and effective dates
EVV (Electronic Visit Verification)
EVV (Electronic Visit Verification)Remote delivery of services via telehealth does not constitute an 'in-home visit' for EVV under the 21st Century Cures Act, so EVV requirements do not apply; states may choose to apply EVV to such services
State optionStates may elect to apply EVV requirements to telehealth-delivered home services though not required
ApplicabilityEVV statutory requirement applies to in-home visits; remote telehealth delivery is distinct
FFP / Covered Outpatient Drug
FFP / Covered Outpatient DrugStates must cover COVID-19 testing and treatments (including EUA drugs) to claim enhanced FMAP; certain drugs may be covered at state option when not meeting 'covered outpatient drug' definition
Rebate and COD considerationsDrugs not meeting covered outpatient drug definition (non-medically accepted indications) may be covered as prescribed drugs under 1905(a)(12) but are not subject to rebates under section 1927
State plan descriptions for investigational drugsStates electing to cover investigational or non-COD drugs should include coverage and payment descriptions in the state plan
MFP demonstration services / supplemental demonstration services
MFP demonstration / supplemental servicesMFP demonstration services and supplemental services may be added to support community transitions but are only available to eligible MFP participants and documented in Operational Protocols
Notification not prior approvalStates should notify their MFP Project Officer of programmatic changes; prior CMS approval not required for certain allowable COVID-19 related Operational Protocol changes
365-day limitMFP-funded services are limited to the participant's 365-day enrollment period and cannot be paid with MFP funds after that period
Appendix K (1915(c))
Appendix K (1915(c)) useStates should request Appendix K from CMS HCBS lead when changing a 1915(c) HCBS waiver program during emergencies; Appendix K documents expected operational changes
When to use Appendix K vs. MFPIf changes affect section 1915(c) services, states must follow waiver processes and request Appendix K even if MFP funds are involved
Appendix K submission detailsA completed Appendix K should be submitted for each affected waiver, with CMS providing technical assistance as needed
90-day institutional stay requirement
90-day institutional stay requirementStatutory MFP eligibility requirement: individual must reside at least 90 consecutive days in an inpatient facility; short-term rehab days paid under Medicare excluded
Statutory natureThis requirement is statutory and cannot be modified by PHE flexibilities
ReferenceSection 2403 of PPACA amended section 6071(b)(2)(A) of the DRA to define eligible individual stay requirement
PPE coverage
PPE coverage via state planPPE may be covered for Medicaid beneficiaries if determined medically necessary under the home health medical supplies, equipment, and appliances benefit (42 C.F.R. § 440.70(b)(3))
Appendix K funding for PPEStates can fund PPE for beneficiaries or unpaid caregivers through section 1915(c) Appendix K by adding a service (e.g., medical supplies) when PPE is used to deliver care to the individual
Limits may applyStates may apply limits on amount, duration, and scope as long as benefit meets its purpose
Appendix K PPE funding
Appendix K PPE fundingAppendix K can be used to add PPE-related services (e.g., Extended State Plan Services: Medical Supplies) for beneficiaries or unpaid caregivers when PPE is used to deliver care
Oversight expectationsStates should establish oversight policies to ensure devices and PPE are used to facilitate delivery of waiver services
Phone cards/minutes not fundablePhone cards and minutes of general utility cannot be funded under Appendix K though devices like tablets may be funded as assistive technology
HRSA COVID-19 Claims Reimbursement Program
HRSA COVID-19 Claims Reimbursement ProgramHRSA program reimburses providers directly for testing and treatment of uninsured individuals; providers must enroll in HRSA to receive reimbursement
Two program componentsComponents: (1) reimbursement for COVID-19 testing services; (2) reimbursement for COVID-19 treatment services for the uninsured
Coordination with MedicaidIf HRSA paid but patient was Medicaid-enrolled for the service date, HRSA will recover payments and advise provider to bill Medicaid; Medicaid is payer of last resort
1135 abbreviated enrollment
1135 abbreviated enrollmentSection 1135 abbreviated enrollment is temporary and must be converted to full enrollment or deactivated within 6 months after the PHE is lifted
Temporary streamlining onlyAbbreviated enrollment cannot replace full screening/licensure requirements permanently
Conversion requirementProviders not fully screened/enrolled must cease receiving payment after conversion deadline if not completed
Interim payment (definition)
Interim payment (definition)Periodic interim payments made under a SPA representing payment for services furnished during an interim period, later reconciled to actual claims; overpayments' federal share must be returned per 42 C.F.R. Part 433 Subpart F
SPA requirementsSPA must specify provider qualifications, methodology for computing interim payments, interval, duration, and reconciliation process
No duplicate paymentsInterim payments replace routine claim-based payments during the interim period; duplicate payments (interim plus claim payment) are not permitted
Retainer payment (definition)
Retainer payment (definition)Payments allowing a provider to continue billing for enrolled individuals when circumstances prevent service delivery; amounts tied to services that would have been provided and subject to limits/guardrails
Episode and duration limitsTypically limited to the lesser of 30 consecutive days or bed-hold days; states may authorize up to three 30-day episodes during the disaster
SPA/Appendix K description requiredStates must describe circumstances, methodology, limits, and guardrails (attestations, recoupment) when authorizing retainer payments in SPA or Appendix K
Administrative claiming / MAC
Administrative claiming / MACStates may claim Medicaid administrative match for COVID-19-related administrative activities if costs are allocable and methodology meets requirements; CMS will assist states expeditiously
RMTS participation enforcementDuring the PHE, CMS will not ask states to impose individual district penalties for failing to reach 85% RMTS participation; states may modify MAC Plans to suspend the requirement
Administrative costs not eligible for FMAP increaseAdministrative costs resulting from COVID-19 initiatives are not eligible for the 6.2% FMAP increase under the FFCRA
Policy Summary
Payercoloradoaccess
PolicyCOVID-19 Frequently Asked Questions (FAQs) for State Medicaid and CHIP Agencies
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 6, 2021
Last ReviewJan 6, 2021
Next Review DateJan 6, 2021
Key ActionStates must elect the optional COVID-19 testing eligibility group via a Medicaid Disaster Relief SPA to provide limited testing/diagnosis benefits to uninsured individuals during the PHE.
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