Medicaid During Public Health Emergencies
Federal and state Medicaid programs operate under a distinct legal framework when a public health emergency is declared, unlocking authorities that allow rapid expansion of coverage, relaxation of eligibility verification requirements, and accelerated provider enrollment. This page explains how those emergency authorities are defined, how they are activated, and where their legal limits fall. Understanding these mechanisms is essential for beneficiaries, providers, and policymakers navigating coverage changes during disasters, disease outbreaks, or other declared emergencies.
Definition and scope
A public health emergency in the Medicaid context is a formal declaration — issued at the federal or state level — that triggers specific statutory and regulatory flexibilities under Title XIX of the Social Security Act. Two primary federal mechanisms govern this framework:
Section 1135 Waivers — Authorized under 42 U.S.C. § 1320b-5, these waivers are activated when the President declares a national emergency under the National Emergencies Act and the Secretary of Health and Human Services (HHS) separately declares a public health emergency under 42 U.S.C. § 247d (HHS Public Health Emergency Authority). Section 1135 waivers allow the Centers for Medicare & Medicaid Services (CMS) to waive or modify requirements related to provider enrollment, prior authorization, and cost-sharing obligations.
Section 1115 Demonstration Waivers — A distinct, longer-term authority under 42 U.S.C. § 1315 that allows states to test experimental Medicaid approaches. During emergencies, CMS has used expedited 1115 processes to approve state-specific responses within days rather than the typical months-long review cycle.
The scope of Medicaid emergency authorities covers the 50 states, the District of Columbia, and the 5 U.S. territories that operate Medicaid programs. It does not create automatic national uniformity — each state's approved waiver terms define the specific flexibilities in effect for that jurisdiction. Background on how Medicaid is structured across these jurisdictions is available on the Medicaid Authority homepage.
How it works
When a public health emergency is declared, the activation sequence follows a structured federal-state process:
- Federal declaration: HHS issues a public health emergency determination under 42 U.S.C. § 247d, typically renewable in 90-day increments.
- State request submission: A state Medicaid agency submits a waiver request to CMS identifying which standard Medicaid requirements it seeks to waive or modify.
- CMS review and approval: During an active emergency, CMS may approve 1135 waiver requests retroactive to the date of the emergency declaration, meaning coverage gaps for already-served populations can be retroactively closed.
- Implementation period: Approved flexibilities remain in effect for the duration of the emergency declaration, with an automatic wind-down period — typically 60 days after the emergency ends — during which normal requirements are phased back in (CMS 1135 Waiver FAQ).
- Termination and unwinding: States must notify beneficiaries and re-establish standard eligibility verification processes once the emergency period closes.
A critical operational distinction separates 1135 waivers from 1115 waivers: 1135 waivers are retroactive and tied directly to the emergency timeline, while 1115 demonstration waivers require explicit CMS approval and carry their own independent expiration dates regardless of when the underlying emergency ends.
Common scenarios
Emergency Medicaid flexibilities have been applied across three recurring categories of public health crisis:
Natural disasters — Following hurricanes, floods, or wildfires, CMS has approved 1135 waivers allowing states to temporarily enroll out-of-state providers, waive prior authorization for acute services, and permit Medicaid-enrolled hospitals to operate at non-standard locations. After Hurricane Katrina in 2005, CMS authorized Louisiana, Mississippi, and Alabama to use emergency authorities to serve displaced populations.
Disease outbreaks — During the COVID-19 public health emergency declared in January 2020, the Families First Coronavirus Response Act (P.L. 116-127) included a Medicaid continuous enrollment condition: states that accepted enhanced Federal Medical Assistance Percentage (FMAP) funding — a 6.2 percentage point increase — were required to maintain enrollment for all beneficiaries enrolled as of March 18, 2020, regardless of eligibility changes (CMS Continuous Enrollment Guidance). When that provision ended, the "Medicaid unwinding" process required states to conduct eligibility redeterminations for approximately 94 million enrolled individuals (KFF Medicaid Unwinding Tracker).
Chemical or radiological incidents — In mass-casualty or environmental contamination events, 1135 waivers can waive EMTALA-related screening requirements and allow licensed out-of-state practitioners to provide services under a host state's Medicaid program.
Decision boundaries
Not every crisis qualifies for Medicaid emergency authorities, and not every flexibility is available in every declared emergency. Four boundaries define what is and is not permissible:
Trigger requirement: Emergency Medicaid flexibilities require a concurrent federal public health emergency declaration. A state-only governor's emergency declaration does not independently activate federal 1135 waiver authority, though it may support a state's expedited 1115 application.
Service scope limits: Even under approved waivers, states cannot waive Medicaid's statutory benefit floors — mandatory services enumerated in 42 C.F.R. Part 440 remain required. States can expand, not contract, the benefit package during emergencies.
Duration ceiling: 1135 waivers cannot extend beyond the termination of the federal emergency declaration plus the applicable wind-down period. Any state seeking permanent flexibility must pursue a standard 1115 waiver after the emergency closes.
Cost neutrality in 1115 waivers: Emergency expedited 1115 approvals still carry the statutory requirement that the demonstration not cost the federal government more than it would have cost without the waiver — a constraint that limits how broadly states can expand eligibility without additional congressional appropriations.
For detailed information on standard Medicaid eligibility dimensions and the key dimensions and scopes of Medicaid, those frameworks apply as the baseline from which emergency modifications depart.