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States Handling Lots of Moving Parts as COVID Emergency Ends

By Lauren Kallins and Austin Reid  |  February 22, 2023

Update, March 23, 2023: The Administration on Children and Families has issued a communication on the phaseout of the emergency FMAP and the end of pandemic-era flexibilities for ACF-administered programs.

The Biden administration announced that the COVID-19 national emergency declaration and the public health emergency declaration, in effect since 2020, will expire on May 11. That means the end of numerous pandemic-era flexibilities in Medicaid, Medicare and CHIP programs, as well as private health insurance. It also suggests an additional extension of the pause on student loan payments is unlikely.

The timing of the announcement provides states with at least 60 days’ notice of the end of the emergency as promised by the Department of Health and Human Services. But lots of complex moving parts lie ahead for states in the spring and beyond. The Consolidated Appropriations Act of 2023 ends the Medicaid continuous coverage requirement enacted during the pandemic on March 31. So states will be in the midst of processing their Medicaid redeterminations for the first time in over three years, just as other as significant flexibilities, including those related to vaccines, boosters, tests and treatments, will be ending in May.

Here are some of the most significant changes as the emergency declarations expire:

COVID-19 Tests and Treatments: Access to free COVID-19 at-home tests and some treatments will no longer be federally required for Medicare beneficiaries or people with private insurance once the declarations expire in May, though Medicare and private insurance will continue to cover the cost of tests and vaccines ordered by a doctor. Medicaid and CHIP recipients will continue to receive all federally recommended vaccines at no cost per the Inflation Reduction Act of 2022, but federally mandated coverage for at-home tests and COVID-19 testing and treatment will end 15 months after the end of the emergency. Federal funding of testing, treatments and vaccines for people without insurance ran out in April 2022.

Emergency Use Authorization for Medical Countermeasures: HHS has not yet announced the expiration date for this declaration, which fast-tracked the use of tests, vaccines and treatments deemed safe but not formally approved by the Food and Drug Administration.

Head Start: Pandemic-era administrative and fiscal flexibilities will end when the public health emergency expires.

Immigration: Federal Title 42 expulsions will end with the public health emergency. Title 42 has been used since the outset of the pandemic to expel migrants who have unlawfully crossed into the United States. The statute allows the government to take emergency action to prevent the introduction of communicable diseases, including by stopping border crossings during a public health emergency. The Department of Homeland Security has announced new border enforcement policies to tackle the transition away from Title 42.

Liability Immunity: HHS issued a declaration in 2020 that provides liability immunity to pharmacists and other health care providers who vaccinate people in states other than the ones where the provider is licensed. The declaration is scheduled to expire on Oct. 1, 2024.

Medicaid Eligibility and Increased FMAP: As NCSL has reported, the continuous coverage mandate, and its corresponding 6.2% Federal Medical Assistance Percentage bump, will end on March 31. States were able to begin processing their renewals as early as Feb. 1, with disenrollments ending on April 1, provided certain requirements were met. States will have 12 months to initiate and 14 months to complete all redeterminations. The FMAP bump will decrease from 6.2% during the first quarter of calendar year 2023 to 5%, 2.5% and 1.5%, respectively over the next three quarters. Medicaid administrative flexibilities related to redeterminations will continue through June 2024. The Centers for Medicare & Medicaid Services has the most recent guidance.

Medicaid Disaster Relief: Emergency exceptions to state Medicaid programs approved by HHS via state plan amendments will end when the emergency declaration expires or earlier as determined by the states. Exceptions granted pursuant to HHS’ authority under Section 1115 waivers will end 60 days after the emergency expires or earlier if approved by CMS. Section 1135 waivers will expire by the end of the declaration unless CMS grants a grace period, and Section 1915(c) Appendix K emergency waiver provisions will end no later than six months after the emergency ends (Nov. 23, 2023). Appendix K flexibilities in states without an extension generally expired in the first quarter of 2021. Additional information can be found here.

Nursing Homes: While the blanket waiver of training and certification requirements for nurse aides has been lifted, states facing a backlog in their training and testing capacity can still apply for a waiver of the certification requirement. However, that flexibility will end when the emergency declaration ends in May, and nursing homes with numerous nursing aides who are not certified may face increased staffing shortages. In August, it was reported that as many as 300,000 temporary nursing aides nationwide remained uncertified.

SNAP Benefits: Food stamp allocations, which were temporarily increased  during the pandemic, will return to their normal levels in March. A number of states have already stopped providing the emergency allotments. SNAP beneficiaries, who also receive Social Security benefits, may see a decrease in their SNAP benefits because of COLA increases to Social Security that went into effect in January. Other pandemic SNAP waivers will remain in effect until the end of the emergency.

Student Loan Repayment: The U.S. Department of Education has used the public health emergency declaration to extend the student loan repayment pause in effect since March 2020. The department, under both the current and previous administration, extended the pause under a 2003 law that allows the education secretary to modify or waive provisions in the loan program during national emergencies. In November, the department announced a final extension of the loan pause; payments will resume 60 days after litigation over the Biden administration’s debt forgiveness plan is resolved. While other final extensions had been announced, the end of the public health emergency suggests another extension is unlikely under previously used authority.

Telehealth: Medicare beneficiaries may continue to access telehealth through Dec. 31, 2024, per the Consolidated Appropriations Act. These flexibilities otherwise would have expired 151 days after the end of the emergency. The availability of telehealth for Medicaid and CHIP beneficiaries is state-specific with regard to whether the service was tied to federal or state public health emergency declarations. Many states have made Medicaid telehealth a permanent option via their state plans.

Other Programs That May Be Impacted

Child Care Entitlement to States: To receive certain federal child care assistance, states must provide matching funds as determined by the state’s FMAP. The state match was effectively reduced by 6.2% in 2020 when the Families First Coronavirus Response Act authorized the emergency FMAP rate. In 2021, the American Rescue Plan Act permanently increased mandatory and matching appropriations to the Child Care Development Fund by $3.55 billion. This was the first such increase since 2006, and the funds were available to states, U.S. territories and tribes. The required state match was waived for 2021 and 2022.

Child Support Enforcement: States are required to reimburse the federal government for its share of child support payments collected by states for families who receive TANF. The amount a state owes to the federal government is based on the state’s FMAP rate.

CHIP Funding: Federal funding for the Children’s Health Insurance Program is matched at a higher federal rate: “enhanced” FMAP (E-FMAP), as compared with regular Medicaid. CHIP funding increased during the health emergency. Go here for a list of state and territory FMAP and E-FMAPs from fiscal years 2020-23.

Foster Care (IV-E Program): Among other things, this program funds foster care maintenance, adoption assistance and guardianship assistance. The federal share of the funding is tied to a state’s or tribe’s FMAP. (Other expenses, including administration and training, are not affected by an increase in the FMAP). Find additional information, including specific FMAPs, here.

PEAF: Though not tied to the end of the health emergency, the $1 billion Pandemic Emergency Assistance Fund provided short-term assistance to Washington, D.C., and eligible states, territories and tribes operating a TANF program. The funds, which were to be allocated to needy families impacted by the pandemic, could be used only for non-recurring, pandemic-related needs; families need not have been eligible for TANF cash assistance. The funds were to be disbursed beginning April 1, 2021, and fully expended by Sept. 30, 2022.

TANF Contingency Fund: Created in 1996 to help states and the District of Columbia meet the needs of families during periods of economic downturn, this funding supplements a state’s TANF block grant award. The federal match is based on a state’s FMAP for the fiscal year for which funds were awarded. (HHS offers guidance here.)

Lauren Kallins is a legislative director and Austin Reid is a senior legislative director in NCSL’s State-Federal Affairs Program.


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