Hawaii Flooding 2026 Disaster Relief Request 2

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 12, 2026

Meredith Nichols
State of Hawaii Department of Human Services
Office of the Director
PO Box 339
Honolulu, Hawaii 96809-0339

Re: Section 1135 Flexibilities Requested on May 06, 2026

Dear Acting Director Nichols:
On April 15, 2026, the President of the United States issued a proclamation retroactive to March 10, 2026,
that the 2026 Hawaii Flooding 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
21, 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 21, 2026, with a retroactive effective date of March 10, 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 May 06, 2026 detailed federal Medicaid requirements that pose issues or
challenges for the health care delivery system in Hawaii. Below, please find a response to each of your
requests for modifications, pursuant to section 1135 of the Act, to address the challenges posed by the
2026 Hawaii Flooding PHE. To the extent the requirements the state requested to waive or modify apply to
the Children's Health Insurance Program (CHIP), the state 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 Hawaii. 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

HAWAII
APPROVAL OF FEDERAL SECTION 1135 WAIVER REQUESTS

CMS Response: May 12, 2026

To the extent applicable, the following waivers and modifications also apply to CHIP.

Managed Care Appeals, Fair Hearings, and Continuation of Benefits
Modify timelines to resolve appeals

The requirements of 42 C.F.R. § 438.408(f)(1) establish that an enrollee may request a state fair hearing
only after receiving a notice that the Managed Care Organization, Prepaid Inpatient Health Plan or Prepaid
Ambulatory Health Plan is upholding the adverse benefit determination but also permits, at 42 C.F.R. §
438.408(c)(3) and (f)(l)(i) that an enrollee's appeal may be deemed denied and the appeal process of the
managed care plan exhausted (such that the state fair hearing may be requested) if the managed care plan
fails to meet the timing and notice requirements of 42 C.F.R. § 438.408. Pursuant to section 1135(b)(5) of
the Act, CMS is granting authority to modify requirements in 42 C.F.R. § 438.408(f)(1) which authorizes the
state to modify the timeline for managed care plans to resolve appeals to no less than one day. If the state
uses this authority, it would mean that all appeals filed through the end of the PHE are deemed to satisfy
the exhaustion requirement in 42 C.F.R. § 438.408(f)(1) after one day (or more, if that is the timeline
elected by the state) and allow enrollees to file an appeal to the state fair hearing level.

Modify state fair hearings timelines

Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify timeframes in 42 C.F.R. §
438.408(f)(2) for managed care enrollees to exercise their appeal rights. If the 120-day deadline to request
an appeal occurred during the PHE, managed care enrollees will have more than 120 days from the date of
the managed care plan's notice of resolution of an appeal to request a state fair hearing (e.g. additional 120
days).

Modify continuation of benefits timelines

Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify timeframes at 42 C.F.R. §
438.420(a)(i) through the end of the PHE. The modified timeframes will allow the managed care plan to
continue benefits if requested within the current 10-day timeframe or reinstate benefits when the individual
requests continuation of benefits between 11 and 30 days after receiving notice if the managed care plan
has not yet made a decision on the appeal or the state fair hearing is pending. This flexibility may be used
provided that the managed care plan may not seek reimbursement or payment for the additional days of
services furnished during this period (aside from otherwise applicable cost sharing, if any) from the
enrollee.

Modify authorization decision timelines

Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify timeframes in 42 C.F.R. §
438.210(d)(1)(ii) and (2)(ii) for two possible extensions up to 90 days each to allow the managed care plan
more time to collect additional information needed to make an authorization decision that is favorable to the
enrollee. If an authorization decision is not made within the first 90-day extension timeframe due to the
PHE, the managed care plan may modify the timeframe to provide an additional 90-day extension, provided
that the managed care plan continue to authorize and pay for the service(s) until a decision is made and
does not seek reimbursement or payment for the services furnished during this additional period (other than
otherwise applicable cost sharing, if any) from the enrollee in the event of an adverse decision. If the
service authorization decision is adverse to the enrollee, the plan must provide timely and adequate notice
of adverse benefit determination per the requirements of 42 C.F.R. § 438.404. For example, insufficient
information within the 14-day time period could lead to a decision to deny the service authorization. During
the extension period of up to 180 days, the managed care plan will authorize and pay for the services
based on the information available until the assessment can be completed.

Modify adverse benefit appeals filing timelines

Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify timeframes in 42 C.F.R. §
438.402(c)(2)(ii) to extend the time period to file an appeal from 60 to 120 days following the receipt of an
adverse benefit determination to allow more time for the enrollee to file a request for an internal appeal with
the managed care plan. The managed care plan will continue to authorize and pay for the service(s) until a
decision is made and may not seek reimbursement or payment for the services furnished during this
additional period (other than otherwise applicable cost sharing, if any) from the enrollee in the event of an
adverse decision. For example, the timeframe extension from 60 to 120 will allow the enrollee more time to
effectively utilize the managed care plan’s appeal process. This ensures the enrollees continued access to
services extension period and does not impact the enrollee’s right to fair hearing should they exhaust the
plan’s appeal process.

Modify standard appeals timelines

Pursuant to section 1135(b)(5) of the Act, CMS is granting the authority to modify timeframes in 42 C.F.R. §
438.408(c)(1)(ii) for standard appeals from 14 days to 30 days. This modification allows the managed care
plan additional time to obtain necessary information, if the delay is in the enrollee’s interest such as to
gather information necessary for a decision that is favorable to the enrollee; the managed care plan must
continue to authorize and pay for the service(s) until a decision is made and may not seek reimbursement
or payment for the services furnished during this additional period (aside from otherwise applicable cost
sharing, if any) from the enrollee in the event of an adverse decision. For example, insufficient information
within the 14-day time period could lead a decision to deny the service authorization. During the extension
period of up to 30 days, the managed care plan will authorize and pay for the services based on the
information available until the assessment can be completed.

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:
application fees, criminal background checks, 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:
a. OIG exclusion list
b. 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:
a. Issue no new temporary provisional enrollments after the date that the PHE is lifted,
b. 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
c. Allow a retroactive effective date for provisional temporary enrollments that is no earlier than
March 10, 2026.

Pause revalidation deadlines

Pursuant to section 1135(b)(1)(B) of the Act, CMS is approving the state’s request to temporarily pause
revalidation for providers located in the state or are otherwise directly impacted by the emergency.
If the state pauses revalidation for providers with revalidation due dates that fall during the PHE, the state
would recalculate the provider’s revalidation due date by adding six months plus the length of the PHE to
the provider’s original revalidation due date. For instance, if the provider’s revalidation due date was April 1,
2021 and the PHE lasted 12 months, the provider’s new revalidation due date would be October 1, 2022
(April 1, 2021 + six months + 12 months).

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 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.

HAWAII
FEDERAL SECTION 1135 WAIVER REQUESTS UNDER REVIEW

CMS Response: May 12, 2026

Please see below for the items that remain under CMS review.

Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered
Service Plans - Initial Independent Assessment of Need

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to delay the initial 1915(i) State Plan HCBS
benefit independent assessment of need until after the individual begins receiving services to facilitate
access to initial services. CMS encourages states to complete these initial assessments via telehealth as
resources permit during the PHE. All initial assessments delayed by the PHE must be completed within 90
days of the of the PHE conclusion. - 42 C.F.R. § 441.720(a)

Long Term Services and Supports (LTSS) - PASRR
Pursuant to section 1135(b)(5) of the Act, delays Pre-Admission Screening and Annual Resident Review
(PASRR) Level I and Level II Assessments for 30 days from the date of each individual's admission. -
Section 1919(e)(7) of the Act and 42 C.F.R. § 483.112

Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered
Service Plans - Reevaluation of 1915(i) Eligibility

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to delay the 1915(i) State Plan HCBS benefit
annual required re-evaluation of 1915(i) eligibility to allow services to continue until the re-evaluation can
occur. All reevaluations delayed by the PHE must be completed within 12 months of the original due date. -
42 C.F.R. § 441.715(e)

Long Term Services and Supports (LTSS) - 1915(c) Level of Care and Person-Centered Service Plan
Timelines - Initial Evaluation of Need

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to delay 1915(c) HCBS Waiver Level of Care
(LOC) Evaluation of Need until after the individual begins receiving services in order to facilitate access to
initial services. Initial evaluations of eligibility must be completed within 90 days of the PHE conclusion. - 42
C.F.R. § 441.302(c)(1)

Long Term Services and Supports (LTSS) - Person Centered Plan Beneficiary and Provider
Signatures - 1915(c)

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to waive or modify the requirement to obtain
beneficiary and provider signatures of HCBS Person-Centered Service Plan under 42 C.F.R. §
441.301(c)(2)(ix) for 1915(c) waiver programs, 42 C.F.R. § 441.725(b)(9) for 1915(i) State Plan HCBS
benefit, and 42 C.F.R. § 441.540(b)(9) for 1915(k) Community First Choice programs, allowing states to
permit documented verbal consent as an alternate to the regulatory requirement for a signature on the
person-centered service plans from beneficiaries and all providers responsible for its implementation.

Long Term Services and Supports (LTSS) - 1915(c) Level of Care and Person-Centered Service Plan
Timelines - Review and Revision of Person-Centered Service Plan

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to delay the review and revision of the person-
centered service plan beyond 12 months. CMS clarifies that this waiver does not eliminate the requirement
that the person-centered service plan be updated when the individual requests a revision and/or when the
circumstances or needs of the individual change significantly. CMS also encourages states to complete
these reviews and revisions of the person-centered service plan via telehealth as resources permit during
the PHE. All reviews/revisions delayed by the PHE must be completed within 12 months of the original due
date. - 42 C.F.R. § 441.301(c)(3)

Long Term Services and Supports (LTSS) - Person Centered Plan Beneficiary and Provider
Signatures - HCBS services in approved 1115 Demonstration

Long Term Services and Supports (LTSS) - 1915(c) Level of Care and Person-Centered Service Plan
Timelines - Reevaluation

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to extend the 1915(c) HCBS Waiver Level of
Care (LOC) reevaluation to allow services to continue until the reassessment can occur. All reevaluations
delayed by the PHE must be completed within 12 months of the original due date. - 42 C.F.R. §
441.302(c)(2)

Long Term Services and Supports (LTSS) - 1915(i) Evaluations, Assessments and Person-Centered
Service Plans - Reassessments of Need

Pursuant to section 1135(b)(1)(B) of the Act, allows a state to delay the 1915(i) State Plan HCBS benefit
annual required independent reassessment of need to allow services to continue until the reassessment
can occur. All reevaluations delayed by the PHE public health emergency must be completed within 12
months of the original due date. - 42 C.F.R. § 441.720(b)

Collection

Federal Disaster Resources