DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
601 East 12th Street, Room 355
Kansas City, Missouri 64106-2898
Medicaid and CHIP Operations Group
July 14, 2026
Theresa C. Arriola, MBA
Director
Department of Public Health and Social Services
155 Hesler Place
Hagatna, GU 96910
Re: Section 1135 Flexibilities Requested on July 9, 2026
Dear Director Arriola:
On July 3, 2026, the President of the United States issued a proclamation that 2026 Super Typhoon Bavi constitutes an emergency by the authorities vested in the President by the Constitution and the laws of the United States, including sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq.), and consistent with section 1135 of the Social Security Act (the Act). On July 9, 2026, pursuant to section 1135(b) of the Act, the Secretary of the United States Department of Health and Human Services (HHS) declared a public health emergency (PHE), invoking the authority to waive or modify certain requirements of titles XVIII, XIX, and XXI of the Act. During a PHE, the Centers for Medicare and Medicaid Services (CMS) may approve the use of section 1135 authority to help ensure that sufficient health care items and services are available to meet the needs of individuals enrolled in CMS programs and to ensure that health care providers that furnish such items and services in good faith, but are unable to comply with one or more of such requirements, may be reimbursed for such items and services and exempted from sanctions for such noncompliance, absent any determination of fraud or abuse. This authority took effect as of July 9, 2026, with a retroactive effective date of July 2, 2026. The emergency period will terminate, and section 1135 waivers will no longer be available, upon termination of the PHE, including any extensions.
Your submission to CMS on July 9, 2026 detailed federal Medicaid requirements that pose issues or challenges for the health care delivery system in Guam. Below, please find a response to each of your requests for waivers or modifications, pursuant to section 1135 of the Act, to address the challenges posed by 2026 Super Typhoon Bavi. To the extent the requirements requested to waive or modify apply to the Children's Health Insurance Program (CHIP), Guam may apply the approved flexibilities to CHIP.
We appreciate the efforts of you and your staff in responding to the needs of the residents and health care community in Guam. Please contact your state lead if you have any questions or need additional information.
Sincerely,
Courtney Miller
Director
cc:
Dan Brillman
Caprice Knapp
Anne Marie Costello
Courtney Miller
Barbara Richards
GUAM
APPROVAL OF FEDERAL SECTION 1135 WAIVER REQUESTS
CMS Response: July 14, 2026
To the extent applicable, the following waivers and modifications also apply to CHIP.
Fee for Service and Eligibility Fair Hearings
Extend fair hearing request timelines
Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify requirements in 42 C.F.R. § 431.221(d) to allow applicants and beneficiaries to have more than 90 days to request a fair hearing for eligibility or fee-for-service appeals by permitting extensions of the timeline to file a fair hearing request (e.g. additional time more than 90 days). This waiver supplements the timeframe in 42 C.F.R. § 431.221(d), which requires states to choose a reasonable timeframe for individuals to request a fair hearing not to exceed 90 days for eligibility or fee-for-service appeals.
Extend timelines for reinstatement of benefits
Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify requirements in 42 C.F.R. § 431.231(a) to allow states the option to reinstate services if a beneficiary requests a fair hearing more than 10 days after the date of action (e.g., the date of termination), but not to exceed the time permitted (under either the state plan or under an approved section 1135 waiver) for beneficiaries to request a fair hearing. This waiver supplements the timeframe in 42 C.F.R. § 431.231(a), which gives states the option to reinstate services and benefits for beneficiaries who request a fair hearing not more than 10 days after the date of action. The state should reinstate the beneficiary’s services and benefits as quickly as practicable.
Provider Enrollment
With respect to providers not already enrolled with another State Medicaid Agency (SMA) or Medicare, pursuant to section 1135(b)(1) and (b)(2) of the Act, CMS waives the following screening requirements: licensing requirements, and site visits, so the state may provisionally, temporarily enroll the providers for the duration of the PHE.
CMS is granting this waiver authority to allow the state to temporarily enroll providers who are not currently enrolled with another SMA or Medicare so long as the state meets the following minimum requirements:
- Must collect minimum data requirements in order to file and process claims, including, but not limited to NPI.
- Must collect Social Security Number, Employer Identification Number, and Taxpayer Identification Number (SSN/EIN/TIN), as applicable, in order to perform the following screening requirements:
- OIG exclusion list
- State licensure – provider must be licensed, and legally authorized to practice or deliver the services for which they file claims, in at least one state/territory
- The state must also:
- Issue no new temporary provisional enrollments after the date that the PHE is lifted,
- Cease payment to providers who are temporarily enrolled within six months from the termination of the PHE, including any extensions, unless a provider has submitted an application that meets all requirements for Medicaid participation and that application was subsequently reviewed and approved by the state before the end of the six-month period after the termination of the PHE, including any extensions, and
- Allow a retroactive effective date for provisional temporary enrollments that is no earlier than July 2, 2026.
Allow out-of-state provider reimbursement
Your State Medicaid Agency (SMA) currently has the authority to rely upon provider enrollment screenings performed by other SMAs and by Medicare. This guidance can be found in section 1.5.3.B. of the Medicaid Provider Enrollment Compendium (MPEC) https://www.medicaid.gov/sites/default/files/2021-05/mpec-3222021.pdf (PDF, 903.54 KB)
As a result, your SMA is authorized to provisionally, temporarily enroll providers who are enrolled with another SMA or Medicare for the duration of the PHE.
As described in section 1.5.1.B.2.c of the MPEC, your SMA may reimburse otherwise payable claims from out-of-state providers not enrolled with your SMA if the following criteria are met:
- The item or service is furnished by an institutional provider, individual practitioner, or pharmacy at an out-of-state/territory practice location– i.e., located outside the geographical boundaries of the reimbursing state/territory’s Medicaid plan,
- The National Provider Identifier (NPI) of the furnishing provider is represented on the claim,
- The furnishing provider is enrolled and in an “approved” status in Medicare or in another state/territory’s Medicaid plan,
- The claim represents services furnished, and
- The claim represents either:
- A single instance of care furnished over a 180-day period, or
- Multiple instances of care furnished to a single participant, over a 180-day period.
For claims for services provided to Medicaid participants enrolled with your SMA, CMS waives the fifth criterion listed above under section 1135(b)(1) of the Act. Therefore, for the duration of the PHE, your SMA may reimburse out-of-state providers for multiple instances of care to multiple participants, so long as the other criteria listed above are met.
Home Health State Plan Services Timeframe (Face-to-Face Encounters)
Pursuant to section 1135(b)(5) of the Act, CMS approves a waiver allowing the state to modify the deadline so home health state plan face-to-face encounters do not need to be completed before the start of services and may occur at the earliest time, not to exceed 12 months from the start of service. - 42 C.F.R §§ 440.70(f)(1), 440.70(f)(2)
Clinic Facility Requirement
Allow provision of clinic services via telehealth
Pursuant to section 1135(b)(1)(B) of the Act, CMS approves a waiver to permit the state and clinic to temporarily designate a clinic practitioner’s location as part of the clinic facility only to the extent necessary so that clinic services may be provided via telehealth when neither the patient nor practitioner is physically onsite at the clinic. Services provided via telehealth in clinic practitioners’ homes (or another location) will be considered to be provided at the clinic. - 42 C.F.R. § 440.90(a)
Allow provision of clinic services in alternative settings
Pursuant to section 1135(b)(1)(B) of the Act, CMS approves a waiver allowing the state and clinic to temporarily designate a clinic practitioner’s location as part of the clinic facility in order to ensure access to health services that would otherwise be unavailable during the PHE. This waiver is provided only to the extent necessary so that clinic services may be delivered when neither the patient nor practitioner is physically onsite at the clinic. The waiver permits services provided in (1) senior centers, (2) evacuation centers and/or shelters, (3) churches, (4) schools, (5) libraries, and (6) other emergency location as deemed appropriate by the State Medicaid Agency to be considered as provided at the clinic for purposes of 42 C.F.R. § 440.90(a).