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Policy Round-Up: PHE Unwinding

May 15, 2023
Vicki Gottlich, Deputy Administrator for Policy and Evaluation

The federal Public Health Emergency (PHE) and Major Disaster Declaration (MDD) for COVID-19 ended Thursday, May 11, and federally funded programs are continuing the process of returning to normal operations. This transition will end the temporary, but significant, changes made to Medicaid enrollment and eligibility rules. It will also impact a variety of programs across the federal government.

In March, we wrote about the end of the “continuous enrollment” provision for Medicaid enacted under the Families First Coronavirus Response Act. That blog talked about how the aging and disability networks can help ensure that people do not lose Medicaid coverage if they remain eligible and how people who are no longer eligible can find other coverage options.

This Unwinding Round-Up includes information and resources on some of the other ways the return to normal operations will impact older adults, people with disabilities, caregivers, and the disability and aging networks. For additional information and the latest resources, visit our “unwinding” page on

In this round up:

  • What you need to know about changes in Medicaid HCBS flexibilities
  • CMS informational bulletin on implications for Medicaid and CHIP
  • Impact on vaccines and testing
  • Changes for home visits for VA Program of Comprehensive Assistance for Family Caregivers
  • Additional fact sheets and resources

Medicaid HCBS flexibilities: What’s changing?

During a Public Health Emergency, states have additional flexibilities to respond to the unique needs created by the emergency. During the COVID-19 pandemic, all states took advantage of some combination of these special emergency flexibilities to modify and strengthen their Medicaid home and community-based services (HCBS) programs. These changes helped older adults and disabled people to continue living in the community. For example, states used emergency flexibilities to:

  • Expand services like home-delivered meals and medical supplies and equipment.
  • Expand “allowable providers” to include family caregivers. This important provision allowed families to receive pay for the support they provide.
  • Provide temporary rate increases and enhancements for service providers, particularly for direct care professionals.
  • Suspend prior authorization requirements and/or cost sharing for certain benefits.
  • Conduct HCBS assessments, evaluations, and person-centered planning virtually.
  • Suspend certain requirements related to provider credentialing and enrollment.

What do aging and disability network partners need to know?

The flexibilities that allowed for these changes to HCBS programs can remain in place for up to six months after the end of the PHE (November 11, 2023). In addition, many of these changes can be extended indefinitely if a state chooses to make them part of their regular Medicaid HCBS waiver programs. States are exploring these options, many of which have a significant impact on disabled people, older adults, and families. We encourage you to work with your state Medicaid agency to ensure that the needs of people with disabilities and older adults — and how these changes have improved the state’s ability to meet them — are understood and considered. 

For example, prior to the pandemic, only a portion of states allowed family caregivers to be paid to provide HCBS (and most only offered this option to some populations). Under PHE flexibilities, most states took advantage of opportunities to expand payment for services provided by family caregivers, and many are considering permanently incorporating these expansions into their Medicaid HCBS waiver programs. This provision helps to address one of the most pressing needs of family caregivers, which is tremendously impactful in its own right. That impact is magnified, however, when considered in light of the shortage of direct care professionals, which has reached crisis levels in recent years.

From CMS: Informational bulletin on implications for Medicaid and CHIP

A new informational bulletin from CMS details what the end of the COVID-19 Public Health Emergency and National Emergency mean for Medicaid and the Children’s Health Insurance Program (CHIP).

 Key changes noted in the bulletin include:

  • The requirement for state Medicaid and CHIP programs to cover COVID-19 vaccines (and their administration), testing, and treatments without cost-sharing will end on September 30, 2024. The requirement to cover the treatment of conditions that may seriously complicate the treatment of COVID-19, while a person has (or is presumed to have) COVID-19 also will end.
  • States have received 100% matching federal funds for COVID-19 vaccines and their administration. This enhanced funding will end on September 30, 2024.
  • The option to provide Medicaid coverage for COVID-19 vaccinations, testing, and treatment to uninsured individuals and receive 100% matching federal funds for coverage for those individuals expired May 11 (15 states and three territories had taken advantage of this option).
  • Since the National Emergency began in 2020, states submitting a Medicaid Disaster Relief State Plan Amendment (SPA) for COVID-19 have been able to request waivers, known as Section 1135 waivers, to waive or modify the federal SPA effective date, public notice, and tribal consultation requirements. CMS’ authority to approve new waivers under Section 1135 ended when the National Emergency ended on April 10, 2023. CMS can, however, approve waiver requests that were submitted before April 10, 2023.
  • The bulletin also clarifies that telehealth flexibilities under Medicaid and CHIP are not tied to the PHE. These telehealth flexibilities were available before the PHE and will continue to be available after. States are encouraged to continue to cover Medicaid and CHIP services when they are delivered via telehealth and CMS has a toolkit available to help states with the continuation, adoption, or expansion of telehealth coverage.

Additional Impact on Vaccination and Testing

In addition to the changes noted above, the end of the PHE ends Medicare’s coverage of up to eight over-the-counter COVID-19 tests each month, as well as requirements for private insurers to do the same (this CMS fact sheet, also available in Spanish, describes how the end of the PHE will impact testing coverage for people with different forms of insurance).

People can still be tested without cost sharing through healthcare providers at over 20,000 community-based testing sites nationwide.

The HHS Bridge Access Program for COVID-19 Vaccines and Treatments also will help to maintain access to COVID vaccines and treatments for people who are uninsured. The program will:

  • Provide support for the existing public sector vaccine safety net, which is implemented through local health departments and federally supported health centers.
  • Create a partnership with pharmacy chains so they can continue offering free COVID-19 vaccinations and treatments to people who are uninsured as they have throughout the PHE.

Ending of Virtual In-Home Visits for VA Program of Comprehensive Assistance for Family Caregivers

The Department of Veteran Affairs (VA) Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides caregiver education and training, mental health counseling respite care, and other benefits. During the PHE, required in-home visits were completed virtually to protect veterans and their caregivers from exposure to COVID-19. Effective May 11, in-home visits will be conducted in person.

 The requirement for in-person home visits applies to:

  • Initial home-care assessments required as part of the evaluation for PCAFC eligibility. This assessment must be conducted before VA can approve and designate a Family Caregiver.
  • Home visits that may be required as part of reassessments. 
  • Wellness contacts required for PCAFC participation, which occur at least annually (typically every 120 days).

More Resources

Last modified on 05/15/2023

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