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Health Care System Resiliency: Preparing the Health Care System for Operation After the Public Health Emergency

Preparing the Health Care System for Operation After the Public Health Emergency: Secretary of Health and Human Services (HHS) Xavier Becerra extended the existing COVID-19 public health emergency (PHE) through October 15, 2022 – and has committed to providing states, health care providers and other stakeholders a 60-day notice before ending the PHE. 

At the beginning of the COVID-19 Public Health Emergency (PHE), CMS used emergency waiver authorities and various regulatory authorities to enable flexibilities so providers could rapidly respond to people impacted by COVID-19. Centers for Medicare and Medicaid Services (CMS) has developed a cross-cutting initiative to use a comprehensive, streamlined approach to reestablish certain health and safety standards and other financial and program requirements at the eventual end of the COVID-19 PHE. This work compliments the work already underway to ensure as many eligible individuals as possible maintain a source of coverage, whether through Medicaid/CHIP, Marketplace, employer coverage, or Medicare. 

CMS wants to help health care providers, facilities, insurers, and other stakeholders prepare for the end of these flexibilities and the return to normal health care standards and operational practices. Information about the status of that PHE and any related actions can be found HERE.


The COVID-19 pandemic revealed opportunities to improve major aspects of the health care system, such as: accommodating advances in technology, connectivity, operations, emergency preparedness; and the need to address underlying disparities in health and health care outcomes, access, and quality across the health care landscape. 

This CMS cross-cutting initiative aims to evaluate CMS-issued PHE Blanket waivers and flexibilities to prepare the health care system for operation after the COVID-19 PHE. This assessment is being done in three concurrent phases: 

1. CMS is assessing the need for continuing certain Blanket waivers based on the current phase of the PHE. For example, do providers currently need the same Blanket waivers they needed early on in the PHE? Since the beginning of the PHE, CMS has both added and terminated flexibilities and waivers as needed. In doing so, CMS considered the impacts on communities ̶including underserved communities ̶and the potential barriers and opportunities that the flexibilities may address. 

2. CMS is assessing which flexibilities would be most useful in a future PHE, such as natural and manmade disasters and other emergencies, to ensure a rapid response to future emergencies, both locally and nationally, or to address the unique needs of communities who may experience barriers to accessing health care. We will use the lessons learned and assessments of the flexibilities we used to inform what steps we take in responding to future emergencies. We will aim to have this work inform the development of a “playbook” of flexibilities that CMS can turn on quickly if needed in response to an emergency. 

3. CMS is continuing to collaborate with federal partners and the health care industry to ensure that the health care system is holistically prepared for addressing future emergencies. In April 2022, CMS launched the revised CMS National Quality Strategy with a goal of ensuring that all persons receive equitable, high-quality, and value-based care. By implementing provisions in this strategy, we will be ensuring resilience in the health care system to prepare for, and adapt to, future challenges and emergencies. CMS is also focused on advancing health equity as we plan for the eventual end of the PHE. The CMS Framework for Health Equity, released in 2022, sets forth priority areas including standardized data collection and analysis, strengthening our health care workforce – particularly those serving underserved communities – increasing provision of culturally and linguistically appropriate services, and identifying and eliminating barriers underserved communities face in accessing health care and coverage. These priorities are consistent with a number of CMS and HHS initiatives, and also in alignment with Executive Order 13985, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Executive Order 13985 calls on agencies to advance equity through identifying and addressing barriers to equal opportunity that underserved communities may face due to government policies and programs. 

The CMS Behavioral Health Strategy includes pivotal goals aimed at improved mental health, substance use, and pain treatment and services; these have proved especially important during the PHE, where mental health and well-being has been negatively impacted. More Americans have reported depression, anxiety, difficulty sleeping, worsening chronic conditions, social isolation and loneliness, and substance use linked to the pandemic experience.

Many of CMS’ recent strategies, but specifically the CMS National Quality Strategy, the CMS Framework for Health Equity, and the CMS Behavioral Health Strategy, build on what we have learned in the years leading up to the pandemic and during the pandemic itself. By following these frameworks, we can ensure that everyone CMS serves – including members of underserved communities – have access to safe, high-quality health care services and supports. 

As CMS identifies barriers and opportunities for improvement, the needs of each person and community served will be considered and assessed with a health equity lens to ensure our analysis, stakeholder engagement, and policy decisions account for health equity impacts on members of underserved communities and health care professionals disproportionately serving these communities. 


✓ Since the onset of the COVID-19 PHE, we have both added and terminated flexibilities and waivers as needed. Most of the current flexibilities and waivers will end with the eventual termination of the COVID-19 PHE declaration or the arrival of the expiration date of the COVID19 PHE. Telehealth waivers are likely the most significant change in increasing workforce capacity. In addition, CMS waived limitations on practice to allow non-physician clinicians, such as clinical nurse specialists, nurse practitioners and physician assistants, to provide much needed care without a physician being physically present for purposes of supervision. 

✓ CMS finalized rules to implement permanent statutory changes that expand telehealth for behavioral health services in Medicare, which allows for greater access and equitable services for those who may not otherwise connect to mental health service providers. 

✓ CMS determined that certain services added to the Medicare Telehealth Services List will remain on the list through December 31, 2023, allowing additional time for us to evaluate whether the services should be permanently added to the List. 

✓ CMS provided additional Medicare payment for administering the COVID-19 vaccine in the home for certain people with Medicare. 

✓ Our Acute Hospital Care at Home program expanded the agency’s Hospital Without Walls initiative as a part of a comprehensive effort to increase hospital capacity, maximize resources, and combat COVID-19 to keep people safe. The program created additional flexibility that allowed for certain inpatient services to be provided outside of a traditional hospital setting and within a patient’s home.

✓ In response to the changing pandemic, CMS rapidly deployed guidance and implemented a new Medicare initiative to increase access to FDA-approved, at-home, over-the-counter COVID-19 tests. 

✓ CMS released a historic regulation requiring COVID-19 vaccination of health care workers at facilities participating in the Medicare and Medicaid programs to better ensure patient/resident safety and provide stability and uniformity across the nation's health care system with regard to vaccinations. We continue to leverage Medicare’s Quality Improvement Organizations to assist with education and technical assistance to nursing homes regarding vaccines and infection control. 

✓ With steadily increasing vaccination rates for nursing home residents and staff, and with overall improvements in nursing homes’ abilities to respond to COVID-19 outbreaks, in April 2022, CMS announced an end to certain flexibilities for skilled nursing facilities/nursing facilities (SNFs/NFs) and people who receive services from inpatient hospices, intermediate care facilities for people with intellectual disabilities (ICF/IIDs), and end-stage renal disease (ESRD) facilities as they have developed policies or other practices that we believe mitigates the need for certain waivers {Link}. 

✓ In the 2023 proposed Physician Fee Schedule rule, to help address the acute shortage of behavioral health practitioners, CMS proposed to allow licensed professional counselors, marriage and family therapists, and other types of behavioral health practitioners to provide behavioral health services under general (rather than direct) supervision. Additionally, CMS is proposing to pay for clinical psychologists and licensed clinical social workers to provide integrated behavioral health services as part of a Medicare patient’s primary care team. 


CMS used various levers to enable flexibilities so providers could focus on rapidly responding to the needs of patients, residents, and clients. Most waivers and flexibilities will terminate at the conclusion of the PHE – and several have already been terminated. CMS encourages health care providers to prepare for the eventual end of these flexibilities as soon as possible and to begin moving forward to reestablishing previous health and safety standards for and billing practices. 

To help with reestablishing normal practice, CMS has a range of resources available that catalog PHE policies and sub-regulatory flexibilities: 

• CMS 1135 waiver/flexibility request and inquiry portal 

COVID-19 Emergency Declaration Blanket Waivers & Flexibilities for Health Care Providers (PDF)

CMS National Quality Strategy

COVID Vaccine Toolkit 

Fact Sheet-CMS Releases Updated Emergency Preparedness Guidance (PDF) 

CMS Pandemic Plan v. 3.1 Public Release

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