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
April 28, 2026
George Cruz
Director
Commonwealth Medicaid Agency
Office of the Governor
Caller Box 10007
Saipan, MP 96950
Re: Section 1135 Flexibilities Requested on April 28, 2026
Dear Director Cruz:
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 submission to CMS on April 28, 2026 detailed federal Medicaid requirements that pose
issues or challenges for the health care delivery system in Commonwealth of the Northern
Mariana Islands (CNMI). Below, please find a response to your waiver request, pursuant to section
1135 of the Act, to address the challenges posed by 2026 Super Typhoon Sinlaku. To the extent
the requirements CNMI requested to waive or modify apply to the Children's Health Insurance
Program (CHIP), CNMI 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 CNMI. 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
NORTHERN MARIANA ISLANDS
APPROVAL OF FEDERAL SECTION 1135 WAIVER REQUESTS
CMS Response: April 28, 2026
To the extent applicable, the following waivers and modifications also apply to CHIP.
Provider Enrollment
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. A single instance of care furnished over a 180-day period, or
b. 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.