Staying on top of emergency declarations and health care-related flexibilities and waivers due to the COVID-19 public health emergency is more than a full-time job.

"Unprecedented!” It is a word you hear frequently these days and for good reason. Never in our lifetimes has the United States, and the world, experienced all that we are right now with the COVID-19 pandemic and the implications. This is especially true when it comes to emergency declarations and health care-related flexibilities and waivers in the United States. Staying on top of these has been more than a full-time job.

Health and Human Services Secretary Alex Azar declared a nationwide Public Health Emergency (PHE) on January 31, retroactive to January 27. President Trump proclaimed a National Emergency (NE) under the Robert T. Stafford Disaster Relief and Emergency Act on March 13, retroactive to March 1. The declarations of both the Public Health Emergency and the National Emergency allow for flexibilities not otherwise available, such as 1135 Waivers. Additionally, all 50 states have announced major disaster declarations for the first time in U.S. history.

There is no time limit on the duration of a National Emergency; the President has discretion as to when to declare and when to terminate it. In contrast, the declaration of a Public Health Emergency is subject to a 90-day time limit but may be renewed for additional periods, also subject to the 90-day limit. In July, Alex Azar extended the Public Health Emergency for the second time, which takes us out to October 22. It is difficult to predict what will happen after this. Keep in mind that Public Health Emergencies can be targeted to specific areas of the country and do not have to cover the entire country at once. These declarations matter because of the flexibilities associated with them.


If you have been tasked with tracking of all the emergency flexibilities and waivers available as a result of the Public Health and National Emergency declarations, Centauri Health Solutions can help. The table below simplifies the complexity.

1135 Waivers

1135 Waivers have been the most visible. They apply to certain federal Medicare, Medicaid, CHIP, and HIPAA requirements. 1135 Waivers support health care providers and can take the form of a blanket or individual waiver. A blanket waiver applies to everyone and without a request. An individual 1135 Waiver is applied for and must be approved. For the first time in history, all 50 states have an approved 1135 Waiver, and many states have more than one.

Disaster Relief State Plan Amendments

A Medicaid Disaster Relief State Plan Amendment (SPA) offers states the opportunity to apply for flexibilities with their Medicaid programs while a Children’s Health Insurance Program (CHIP) Disaster Relief SPA offers states that have a separate CHIP plan, the opportunity to apply for flexibilities with their CHIP program. A disaster relief Medicaid or CHIP SPA must be approved by the Centers for Medicare & Medicaid Services (CMS) and may only have one effective date. Provisions within the SPA may have different implementation dates after the effective date.

Emergency Section 1115 Medicaid Demonstrations

Emergency Section 1115 Medicaid Demonstrations are used for experimental, pilot or demonstration projects and must be approved by CMS. They can be new or modify an existing 1115 Waiver. The normal public notice process requirements can be waived if the state meets the criteria. Disaster-related demonstrations can be retroactive to the date of the Public Health Emergency. Currently only a handful of states have been approved. There are quite a few of these Emergency Section 1115 Medicaid Demonstrations pending and CMS is delayed in processing them.

Verification Plan Addendum

A Verification Plan describes a state’s verification policies for determining eligibility. During a Public Health Emergency, a state can submit a Verification Plan Addendum to temporarily alter their policies and procedures, effective immediately. CMS approval is not required.

Expiration of Flexibilities and Waivers

When the National or Public Health Emergency declaration ends, including any renewals, most of the flexibilities are supposed to end. Emergency Section 1115 Medicaid Demonstrations end 60 days after the Public Health Emergency ends. CMS, however, is unlikely to put a hard stop to the 130 plus waivers related to Medicare and more than 150 waivers related to Medicaid, according to Kim Brandt, CMS’ principal deputy administrator for policy and operations. CMS is working with the White House on a glide path to phase them out gradually instead of a hard stop. Some will remain permanently.  

What’s next

States are advised to be watchful for CMS communications on the end date for flexibilities and waivers. Centauri Health Solutions is available to help and support providers and health plans alike.

About the author

Shanna Hanson, FHFMA, ACB, is manager of business knowledge at Centauri Health Solutions. In her role, she is responsible for researching and reporting to executive staff on all legislative and environmental changes and trends impacting the company’s health care markets, services, and product development initiatives. This includes strategic knowledge leadership for the company on national health care reform and the Affordable Care Act; she has researched health care reform and the ACA for many years. Prior to her present role, Shanna served 14 years as Human Arc Midwest Operations Leader for its Medicaid eligibility enrollment services. She is a past president of the Healthcare Financial Management Association’s (HFMA) Heart of America Chapter and earned the designation of Fellow of the Healthcare Financial Management Association (FHFMA). Shanna holds the organization’s Certificate of Advanced Technical Study in Mastering Patient Financial Services as well as the Founders Medal of Honor Award. She is a recognized industry writer and speaker on health care and related topics, conducts webinars, and was a frequent HFMA HERe blog contributor Shanna holds a BS degree in business from Oklahoma State University (Stillwater, OK) and several certifications including Master Team Facilitator, Integrative Health Coach, and Toastmaster’s Advanced Communicator Bronze.