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
May 15, 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 April 29, 2026 and May 14, 2026
Dear Director Arriola:
On April 11, 2026, the President of the United States issued a proclamation that 2026 Super Typhoon
Sinlaku 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 April 17, 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 April 17, 2026, with a retroactive effective date of April 11, 2026. The emergency period will terminate,
and section 1135 waivers will no longer be available, upon termination of the PHE, including any
extensions.
Your submissions to CMS on April 29, 2026 and May 14, 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, pursuant to section 1135 of the Act, to address the challenges posed by
the 2026 Super Typhoon Sinlaku. To the extent the requirements Guam 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: May 15, 2026
To the extent applicable, the following waivers and modifications also apply to CHIP.
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).