The COVID-19 pandemic continues to challenge the U.S. health care and public health systems. State legislators, however, are rising to the challenge and pursuing various policy options to effectively respond to COVID-19. This webpage includes key health policy information relating to the pandemic, including legislative trends and state actions, federal action and additional resources.
This section highlights state responses to COVID-19 related to access and coverage, health workforce, public health and health-related appropriations. For a complete list of all COVID-19 legislation, visit NCSL’s State Action on Coronavirus (COVID-19) page.
Scope of Practice and Licensing
Out of concern that an increase in COVID-19 cases may overwhelm the health care system, state officials from both the executive and legislative branches are temporarily waiving certain requirements to mitigate health care workforce barriers. Many states are evaluating scope of practice (SOP) laws, which dictate the practice authority for different health care professionals, to enhance the role of certain providers responding to COVID-19—such as nurse practitioners, physician assistants and pharmacists. For example, Kentucky SB 150 authorizes the Kentucky Board of Medical Licensure, the Kentucky Board of Emergency Medical Services and the Kentucky Board of Nursing to waive SOP requirements allowing providers to practice in all health care settings. The legislation also allows medical students to conduct triage, diagnose and treat patients under the supervision of a licensed health care professional.
Additionally, more than 40 states are temporarily modifying licensing requirements and establishing expedited approval processes to recruit more health care workers during COVID-19. Vermont HB 742 allows the office of professional regulation to relax various licensing requirements for retired and out-of-state health care professionals, including mental health providers. NCSL is tracking the many changes to health care workforce licensing requirements here.
Federal and state officials are pursing policy options to limit liability exposure for health care professionals and/or facilities providing COVID-19-related services. The Coronavirus Aid, Relief, and Economic Security Act provides immunity for volunteer health care providers during the COVID-19 emergency declaration, if a volunteer acts in good faith and within the scope of their medical license.
At least 27 states, the District of Columbia and Puerto Rico have provided some level of immunity for health care workers, health facilities or both during the pandemic through executive or legislative action. Seventeen states, the District of Columbia and Puerto Rico enacted legislation providing liability protections specifically in response to COVID-19. For example, Oklahoma SB 300 provides immunity from civil liability for health care providers and facilities for any loss or harm delivered to a patient believed or confirmed to have COVID-19. Other states already had existing laws providing immunity during a public health emergency. Virginia maintained certain liability protections for health care workers and first responders in cases of emergency, and the governor signed an executive order clarifying the existing statutes extended to health care workers responding to the COVID-19 crisis.
Access and Coverage
All 50 states and the District of Columbia have made some revision to their telehealth policies during the pandemic to increase access to health care services and minimize potential exposure to the coronavirus. To enhance the effectiveness and reach of telehealth, state policymakers are bolstering Medicaid and private insurance coverage, expanding access to different telehealth modalities, and enhancing the number of services delivered via telehealth. Additionally, states are evaluating certain requirements relating to provider licensure, patient/provider relationship standards and originating site criteria. Most of these state actions are temporary for the duration of the pandemic.
Vermont HB 742 encompasses several of these policy strategies by reducing licensing requirements for out-of-state providers, extending private insurance coverage to include teledentistry, requiring coverage for store-and-forward modalities, and requiring private insurance plans to provide the same reimbursement for telehealth as the insurer would for in-person services. Alaska SB 241 permits a provider to deliver certain services to a patient through telehealth without first having to conduct an in-person visit. Minnesota SF 4334 requires coverage for telemedicine services delivered directly to a patient in their own home by expanding the definition of “originating site” to include a patient’s residence.
Private Insurance Coverage
To ensure that the costs of COVID-19 related services do not deter patients from seeking necessary care, federal and state policymakers have looked to limit out-of-pocket expenses for COVID-19 prevention, testing and/or treatment. Federal law requires private health insurance plans to cover COVID-19 testing and federally recommended preventative care, including a vaccine, free of cost-sharing. Some states have established coverage requirements that exceed this federal standard. Additionally, states have established other requirements or recommendations relating to private insurance coverage during the COVID-19 pandemic, such as requiring coverage for COVID-19 treatment without cost-sharing, establishing special enrollment periods in states operating their own individual insurance marketplace, or requiring coverage for early prescription drug refills.
While most of these actions have come from the executive branch and departments of insurance, many states have enacted or introduced legislation relating to private insurance and COVID-19. For example, New Jersey SB 2344 requires Medicaid and private health insurance carriers to cover early prescription drug refills for up to a 30-day supply so enrollees can maintain an adequate supply during the pandemic. Louisiana SB 426 requires health insurance carriers to cover COVID-19 diagnostic tests, antibody tests and antiviral drugs for prevention and treatment free of cost-sharing.
With Medicaid covering 1 in 5 Americans—and some studies estimating tens of millions will be newly-eligible for Medicaid coverage after losing their employer-sponsored insurance during the pandemic—policymakers are leveraging the federal-state program within the context of both a public health and economic crisis. The Families First Coronavirus Response Act (Families First Act) provides a temporary 6.2% increase to regular Federal Medical Assistance Percentage rates, which is the portion of federal funding provided to each state for Medicaid expenditures. In order to receive this increased federal funding, states must agree to certain terms and conditions—such as providing continuous coverage for all enrollees, maintaining current eligibility requirements and waiving cost-sharing for COVID-19 testing and treatment. The Families First Act also allows states to cover COVID-19 testing for uninsured individuals through Medicaid, with the federal government covering 100% of the costs for testing. As of January 2021, at least 17 states have received federal approval to implement this option.
Policymakers are also turning to various waiver opportunities to ease certain Medicaid requirements and expand access to vital services. All 50 states and the District of Columbia have received federal approval for emergency Section 1135 Waivers to waive requirements in general areas like prior authorizations for services and provider credentialing. Forty-nine states have received approval for changes to their home and community-based services (HCBS) waivers—or Section 1915(c) Waivers—to ease requirements relating to long-term care for older adults and people with disabilities, populations particularly vulnerable during the pandemic.
Additionally, state legislators and other officials are increasingly focusing on appropriations, financing and provider rate payments for their Medicaid programs in light of COVID-19. For example, Washington HB 2965 authorizes the department of social and health services to determine adequate Medicaid payment rates for nursing facilities responding to COVID-19. Facing budget shortfalls, states are pursuing cost containment strategies to lower Medicaid costs. For instance, Colorado’s FY 2020-2021 budget reduces certain optional benefits (unless the COVID-19 emergency period extends beyond December) and decreases community provider rate payments by 1% for some health care workers treating Medicaid enrollees to help make up for the state’s $3 billion budget deficit.
While hundreds of millions of Americans are protected through vaccination, COVID-19 testing remains a critical tool in targeting public health responses and measuring the spread of the virus. Public health experts and the National Strategy for the COVID-19 Response and Pandemic Preparedness rely on robust testing programs to identify COVID-19 hot spots, make informed decisions and support other key disease-control efforts, such as contact tracing. States have created their own testing plans and taken various actions to address barriers to testing. Legislators are taking an active role to bolster testing efforts and support their state’s capacity to carry out COVID-19 testing.
To supplement federal support, many states have appropriated funding for testing services and supplies. For example, Minnesota SF 4334 approved money from the general fund for the establishment and operation of temporary testing sites and New Mexico HB 1 appropriated $10 million to support COVID-19 testing, contact tracing and vaccine services. Some states, including Massachusetts and Utah, enacted legislation creating a task force or commission to make recommendations on widespread testing implementation. Others established COVID-19 testing task forces through executive and other means, such as the California COVID-19 Testing Task Force and the Pennsylvania National Guard COVID-19 Testing Task Force.
For more information on insurance coverage for testing, please see the section on Access and Coverage.
Contact tracing, the process of identifying and warning individuals who have come in contact with an infectious disease, is another public health measure that has been identified as a key component for a state’s ability to manage the spread of COVID-19. Although this public health tool is well established, the scale and speed required by the extent of COVID-19 cases among the U.S. population is unprecedented.
States are managing contact tracing plans through a variety of approaches; some are leading efforts through their state and local officials, through contracts with another organizations, or a combination of the two. Arizona has taken the latter approach, utilizing state employees, university faculty and students, and the National Guard.
Many state legislatures have enacted legislation to coordinate or fund contact tracing functions. For example, North Carolina SB 808 appropriated a total of $125 million to the Department of Health and Human Services for several COVID-19 mitigation services, including to expand contact tracing infrastructure and to hire temporary staff to augment contact tracing functions—particularly for historically underserved or at-risk populations. New York AB 10567 requires contact tracers to be representative of the cultural and linguistic diversity of the communities in which they serve, to the greatest extent possible. The bill also requires each county health department, except those serving cities with a population of one million or more, to compile and post information about contact tracer worker diversity.
Traditional contact tracing programs include privacy protections for data collected. As contact tracing strategies rely on various digital technologies, some states have explicitly outlined related privacy standards. Kansas HB 2016 prohibits the use of any service or means that use cellphone data to identify or track, directly or indirectly, the movement of persons and South Carolina HB 5202 prevents anyone conducting contact tracing from using any application created for such purpose on a cellular device. South Carolina HB 5202 also requires the department of health to conduct a public awareness campaign to explain the use of contact tracing.
Data Collection and Reporting
Since the first reported case of community spread in the U.S., states have collected large amounts of data regarding the number of cases and deaths among their constituents. The data has informed and guided government response to the pandemic at all levels. Additionally, accessibility to data through the media and internet has increased public knowledge and awareness. COVID-19 data is an important tool not only for monitoring the trajectory of the pandemic and to inform public health initiatives, but also to address inequities across cases, mortality, testing and vaccination rates across many demographic factors.
The pandemic has disproportionately impacted Black, Hispanic and Latino communities through higher infection rates, hospitalizations and deaths. Data also suggests these populations are receiving vaccines at lower rates than White Americans, although recent vaccinations seem to be reaching larger shares of minority populations compared to overall vaccinations. Some states have enacted strategies to monitor such disparities in data. For example, Louisiana SR 74 urged the state department of health to include demographic data and study differential health impacts of COVID-19 on racial and ethnic minority populations in the state. Massachusetts HB 4672 similarly requires the state department of health to include demographic information in its COVID-19 data reports. The bill requires that infected people in long-term care facilities as well as state and county correctional facilities be included in reported data.
States have also focused on bolstering their capacities to collect and analyze data. North Carolina HB 1023 funds the state office of state budget and management to build data exchanges to enable the use of near real-time data and allow the state to better understand the impact of the virus and quickly identify hotspots. Georgia HB 80 appropriated $27 million using state and federal funds to replace and modernize the public health surveillance system to improve the state’s current COVID-19 response and future epidemiologic surveillance capacity.
Masks or Face Coverings
Federal guidance on wearing masks or face coverings has changed over the course of the pandemic due to many factors, including vaccination rates, variants and studies on the efficacy of the public health measure. In response to the rapid spread of the Delta variant, CDC recommends everyone who is able, including fully vaccinated people, wear masks in public indoor places in areas of substantial or high transmission. States have taken different approaches on implementing or prohibiting mask requirements.
Some states implemented statewide mask requirements to curb the spread of COVID-19. For many states, mandates are at the discretion of executive and local leaders though the legislature may be involved. For example, the Maryland Joint Committee on Administrative, Executive and Legislative Review, compromised of 19 state representatives and senators, approved emergency regulatory changes that allow the state board of education to implement a statewide school mask mandate. Conversely, several state legislatures have acted to regulate the powers of local officials and governing bodies to implement mandates. For example, North Dakota HB 1323 prevents statewide elected officials and the state health officer from mandating any individual use a face mask, shield or covering and Arkansas SB 590 prohibits the mandatory use of face masks, shields or other coverings.
The U.S. Food and Drug Administration issued emergency use authorizations for the first vaccines to protect against COVID-19 in December 2020. In August 2021, the FDA fully approved the vaccine for individuals 16 and up. In September 2021, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) and the CDC Director issued recommendations for COVID-19 boosters for older Americans, people with underlying medical conditions and people with occupations that increase their risk of exposure and transmission. ACIP continues to provide updated COVID-19 vaccine recommendations, which have expanded from groups at high risk of illness during initial phases to everyone in the United States aged 12 years and older.
As the vaccine supply has become more widely available and more groups are eligible for inoculation, immunization efforts have shifted to focus on accessibility and engaging communities that may face barriers to or be hesitant to get the vaccine. State policymakers can play a role in several policy areas that support COVID-19 vaccine infrastructure and access, including public health infrastructure, state vaccine plans, vaccine accessibility and public outreach. For example Virginia HB 5005 provides for the convening of a work group with the state’s chief diversity, equity and inclusion officer and other stakeholders to identify and develop plans to ensure vaccines are equitably distributed and accessible to all throughout the state and Pennsylvania HB 326 directed the state’s National Guard to help plan vaccination sites in each region of the state for community distribution and administration of COVID-19 vaccines. State legislatures can also work with key stakeholders in their state, such as state health agencies and community-based organizations, to identify strategies that remove barriers and streamline access to and public confidence in coronavirus vaccines.
In addition to increasing access, several state legislatures have taken action to prohibit discrimination based on a person’s vaccination status or to prohibit mandatory COVID-19 vaccines, such as Montana HB 702 and Utah HB 308, respectively. Other bills relate to students or minors, including Oklahoma SB 658, which prohibits schools from requiring vaccination against COVID-19 or a vaccine passport as a condition for enrollment or attendance.
For more information and state examples, you can refer to our Health Policy Snapshot: COVID-19 Vaccine Infrastructure and Access and our Vaccine Policy Toolkit. Please visit NCSL’s State Action on COVID-19 Database to view all legislation referencing the COVID-19 vaccine (under Health: Vaccine).
Long-Term Care Facility Oversight
With long-term care (LTC) residents and staff making up a significant portion of COVID-19 related infections and deaths, federal and state policymakers are looking to bolster oversight and guidance for LTC facilities. In May 2020, the Centers for Medicare and Medicaid Services (CMS) required nursing facilities to report COVID-19 data to the Centers for Disease Control and Prevention (CDC)—and at least 19 states established reporting requirements for assisted living facilities in addition to nursing homes.
State legislators have also pursued additional oversight for LTC facilities. For example, Michigan HB 6137 requires the department of health and human services to post on its website certain COVID-19 related data—including new and total case and death counts—for each nursing home in the state. Georgia HB 987 establishes COVID-specific reporting requirements, such as requiring facilities to notify residents and guardians of new positive cases. Moving forward, the legislation also permanently establishes additional staffing requirements, increases fines for safety and quality violations, and requires facilities to develop pandemic plans for future outbreaks. New Hampshire HB 578 creates a committee to study safety protocols for LTC residents and staff.
Infection Control Protocols
Federal and state policymakers have identified strategies to mitigate the spread of COVID-19 within LTC facilities. CMS published a toolkit on state actions addressing COVID-19 in nursing homes. The toolkit compiles state-level best practices relating to testing, vaccinating residents and staff, accessing personal protective equipment (PPE) and other public health protocols.
Legislatively, states have focused on a number of these topics. Virginia HB 5005 directs the state health commissioner to prioritize COVID-19 testing for nursing home and assisted living facility residents and employees. California SB 275 requires certain providers, including LTC facilities and home health agencies, to maintain a PPE stockpile for future pandemics. Several states—such as Michigan, Mississippi and North Carolina—allocated federal CARES funding to LTC facilities for acquiring PPE and financing other infection control activities.
States are also balancing mitigating transmission through visitation restrictions while combatting social isolation for LTC residents. CMS issued guidance on how to safely allow visits to nursing homes during COVID-19, but visitations requirements vary greatly by state—and likely will continue to evolve as more residents, staff and family members get vaccinated.
To facilitate social connection, New Jersey SB 2785 requires certain LTC facilities to have written isolation prevention plans and ensure the facility has appropriate staff and technology capabilities to prevent isolation during public emergencies. Louisiana HB 43 requires the department of health to develop rules allowing family members and other designated persons to visit residents in nursing homes and adult residential care facilities, with special consideration for residents receiving end-of-life care. Some states—such as Illinois and Minnesota—have developed guidelines for designating essential caregivers, which allow family members or other loved ones to assist with daily activities and provide companionship to residents.
Long-Term Care Rate Increases
Nearly all states have increased Medicaid provider payment rates for certain LTC facilities, home and community-based providers, or both. While these actions have often been through various emergency waiver authorities, some states have pursued rate increases or supplemental funding legislatively. For example, New Jersey AB 4547 provides a temporary 10% rate increase to nursing facilities, with at least 60% of extra funding going towards wage increases for certified nursing assistants and the remaining towards COVID-19 related expenses. Minnesota HF 1 provides a temporary 8.4% rate increase to direct support professionals (e.g., personal care assistants) for wage increases, purchasing PPE and complying with CDC guidelines.