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.
As states work to address the impact of COVID-19 in their communities, many have found widespread testing critical to 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; however, challenges with testing capacity and accessibility persist. 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, have enacted legislation creating a task force or commission to make recommendations on widespread testing implementation. Others have 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.
As testing capacities remain limited, some policymakers are outlining guidelines to prioritize certain vulnerable populations. South Carolina HB 3411, for instance, requires the statewide testing plan to focus testing in rural communities and areas with risk factors for COVID-19. Virginia HB 5005 requires residents and employees of nursing homes and assisted living facilities to receive priority testing, and Massachusetts SB 2984 requires guidelines for testing asymptomatic individuals who work in industries with increased exposure, such as the health care, restaurant and retail industries.
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. A report by the Association of State and Territorial Health Officials and the National Governors Association recommends states pursue a few actions to bolster their contact tracing efforts and ensure an adequate workforce, including identifying new sources of potential workers and removing barriers to hiring and training these workers.
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. Oregon is leading efforts in-house—through the Oregon Health Authority, local and tribal public health authorities and community-based organizations—and Kentucky has outsourced workforce hiring to various private companies.
Many state legislatures are considering or 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. Meanwhile, many states are turning to technological solutions to notify individuals who may have been exposed to the virus. The Association of Public Health Laboratories, in collaboration with Apple, Google and Microsoft, is helping deliver exposure notifications systems to public health agencies. For example, Colorado—one of 23 participating states—uses an opt-in application to tell users when their device comes within six feet of someone who later tests positive.
Sustained increases in COVID-19 caseloads, testing delays and other challenges have led states to alter their contact tracing approaches. When caseloads are particularly high and growing, it can be difficult for tracers to determine which individuals may have been exposed and where, and for them to make contact with positive cases fast enough. The Centers for Disease Control and Prevention (CDC) published updated guidance on prioritizing case investigation and contact tracing in areas where COVID-19 surges are straining resources.
Several states are adopting various changes such as prioritizing high-risk contacts, utilizing new technologies and creating different strategies to conduct case investigations. For instance, Virginia adopted CDC’s guidance to prioritize follow-up of cases and tracing of close contacts for certain groups, including those living or working in congregate settings or those at increased risk of severe illness. In November 2020, the Nebraska Department of Health and Human Services reported temporary measures to most efficiently manage the rise in cases, which include reducing interview questions and call attempts, focusing outreach only to those who test positive and asking those they connect with to notify their own contacts. A blog by the National Academy for State Health Policy highlights additional techniques.
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.
Many bills relating to the collection and reporting of data often expand the scope of the data collected to include additional populations and ensure data is made available to the public. New Jersey SB 2357 requires the state department of health to include data about the age, ethnicity, gender and race of persons who have tested positive for or died from COVID-19 and update this information on its website daily. California SB 932 requires the sexual orientation and gender identity of individuals diagnosed with COVID-19 also be included in reported data.
Massachusetts HB 4672 similarly requires the state department of health to include demographic information in its COVID-19 data reports. The bill also requires that infected people in long-term care facilities as well as state and county correctional facilities be included in reported 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. Louisiana SR 74 urges 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.
The U.S. Food and Drug Administration issued emergency use authorizations for the first vaccines to protect against COVID-19 in December 2020. Shortly after, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) recommended the vaccines for certain groups of people. ACIP provides updated COVID-19 vaccine recommendations, which include the prioritization of health care personnel and residents of long-term care facilities in the first vaccination phase, followed by persons over the age of 75 and non-health care frontline essential workers.
As states and localities administer COVID-19 vaccine doses amid high demand and logistical challenges, they continue to refine existing plans for distribution and administration. Most states are following ACIP’s guidance, although—especially beyond the initial 1A phase—several have diverged from federal guidance and from one another by priority group designation and timeline. A common priority across every state, local and tribal health department remains addressing challenges around funding, capacity and public uptake of the vaccine. State policymakers can work with their state health agencies to identify policies that remove barriers in these areas and streamline access to and public confidence in the vaccine.
The federal government has allocated billions of dollars to support state vaccination efforts and some states are supplementing with additional funds. For example, Michigan SB 748 appropriated $51 million to its health department to support a vaccine strategy. Other states have outlined requirements for their state vaccine plans, including Virginia HB 5005 and Massachusetts HB 5164, which require equitable distribution. Massachusetts HB 5164 requires the design and implementation of its vaccine plan to prioritize communities that have been disproportionately affected by the pandemic, in addition to a public education and outreach campaign on vaccine safety and efficacy that is culturally competent and linguistically diverse.
To help ensure broad access to COVID-19 vaccines, federal rules require private insurance and public programs to provide the vaccine at no cost. The Coronavirus Aid, Relief, and Economic Security (CARES) Act created a fund to reimburse providers who administer the COVID-19 vaccine to uninsured individuals. Some states have pursued their own requirements, such as Maryland HB 1663, which requires private insurance carriers and the state Medicaid program to cover the cost of a COVID-19 vaccine. The federal government has also expanded access by allowing licensed pharmacists to order and administer the COVID-19 vaccine. Several states, including California, Minnesota, New Hampshire and New York, have enacted legislation to expand pharmacists’ authority around COVID-19 vaccine administration. North Carolina SB 704 includes a process for authorizing pharmacists to administer a COVID-19 vaccine through a statewide standing order.
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.