The Biden administration is making another push for telehealth and other digital disease-monitoring tools to become sustainable beyond the pandemic.

The US Department of Health and Human Services announced Monday that it’s giving nearly $55 million to improve access to community health centers that have played a vital role in patient care as the country faced Covid-19.

The new funding is meant to help 29 federally qualified health centers provide better access to telehealth, expand digital disease monitoring and enhance health information technology to make these centers more accessible.

“We’ve learned, especially with Covid, that our health care system has holes in it and unfortunately, people are falling through those holes. And no one wants to be left behind,” HHS Secretary Xavier Becerra told CNN on Monday.

He called federally qualified community health centers a “game-changing” solution to fill those gaps.

“We’re going to help them zero in on virtual care, which we’ve learned through the pandemic is also a lifesaving way of getting to people who often are missed,” he said.

Barriers for virtual care were temporarily removed while Covid-19 is a public health emergency, but some centers are concerned the innovation could disappear.

“We share the angst because we’re going to need authority from Congress in order to be able to continue some of these telehealth opportunities that are available right now … but disappear once we no longer declare this to be a public health emergency,” Becerra said.

There are bills under consideration at the federal level that would remove some of the barriers to telehealth. At the state level, there have been at least 37 states that permanently incorporated telehealth flexibility into state law, according to the National Conference of State Legislatures.

The value of virtual care

This isn’t the federal government’s first move to advance digital health. In August, HHS announced 36 awards of $19 million to expand telehealth nationwide, calling it a “vital tool to improve health equity.” In January, the federal government asked for public input about how digital technology is used and could transform ways people get health care.

“The nonprofits have a tough time getting into some of the new technologies if they don’t have the kind of money it takes to make those kinds of investments. So this money is going to help them move quicker and stay longer and more durably in … virtual care,” Becerra said Monday.

The money can’t come soon enough for clinics such as the South Central Family Health Center in Los Angeles, which is among the groups receiving the $55 million announced on Monday.

South Central, like many centers around the country, couldn’t offer virtual care prior to the pandemic since health centers weren’t reimbursed for those appointments.

When that changed during the pandemic, it made a difference for patients who might otherwise have to forgo care, according to David Roman, the center’s director of development. He described one patient who found herself struggling with depression and anxiety during the pandemic. She wanted to get help, and even scheduled time with the center’s behavioral health team, but kept missing appointments. When the team reached out to find out why, she confessed that while she needed the help, she couldn’t afford to take a day off work for the appointment.

“One day off of work could mean not being able to feed your family that week,” Roman said. Since the center was able to schedule her for virtual appointments for her lunch hour, she hasn’t missed one yet.

Roman said his health center will use the new funding to determine how to provide the best virtual care.

“It will also help us learn how to apply different types of technology to help our patients,” Roman said. For example, he said the clinic cares for almost 4,200 patients with diabetes. After transportation and medicine adherence, the next biggest challenge is communication with their providers. This money will help the center provide remote monitoring devices to some of these patients so that the providers can help keep their diabetes in check.

“This is a technology that has been available to the general public that has insurance that will cover it, but a large number of our patients are not insured,” Roman said — about 40% of the center’s patients. “This is something that will significantly improve the kind of care we can provide.”

Pandemic safety nets

The United States’ 1,400 federally supported community health centers serve as a safety net for around 29 million underinsured or uninsured patients who live in rural and urban areas with high concentrations of poverty. Many patients at these centers have multiple underlying health conditions and the centers act are their only access to primary care. The centers also provide pharmacy services, mental health care, substance use programs and dentistry.

They’ve provided 19.2 million Covid-19 vaccines and two out of three of them have gone to hard-to-reach members in communities of color, according to the National Association of Community Health Centers. The centers have also been a significant source of Covid-19 tests, according to the Kaiser Family Foundation.

Their efforts during the pandemic paid off. In areas where there is an active community health center, there have been fewer Covid-19 deaths and infections, according to an analysis done by the Morehouse School of Medicine and the National Association of Community Health Centers.

The American Rescue Plan gave these health centers an additional $7.3 billion to provide pandemic care, HHS said. The centers, though, have been chronically underfunded and hit even harder this past year with the sharp rise in inflation. Federal government payment models are based on a fixed amount per patient, and they don’t account for inflation.

When there is funding, community health centers can do more. When virtual visits were reimbursed, the number of community centers that offered them increased 132%. Before the pandemic 592 centers offered virtual care, in 2022 it was 1,362, according to Health and Human Services. Virtual visits were up 6,000% during the pandemic, according to HHS.

Another recipient of the new funding, Middletown, Connecticut-based Community Health Center, which has centers throughout the state, will use the money to better understand how to use virtual appointments with patients with behavioral health and medical appointments, said Mark Masselli, the center’s founder and CEO.

“The community we serve is cost conscious. You work at the 7/11 and the thought of catching two busses to go and wait a half hour to be seen for 15 minutes is daunting,” Masselli said. “What if they could just do the appointment from their car at lunch instead. I think out of the pandemic we’re trying to figure out what this new delivery system will look like.”It also want to figure out what self-monitoring tools would work best with patients at home between patient visits.

“Sometimes people feel lost and abandoned between appointments and we think this could be a good tool,” Masselli said.

The center hopes to expand the model of school-based health center virtual care as well. “You simply can’t get a child psychiatrist to every school,” said Masselli. “They have to figure out ways that will be the force multiplier to do this.”

The center will also use the money to train the next generation of providers on how to integrate telehealth into their practice.

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USDA is providing $43 million in new funds to rural healthcare providers, many of whom have earmarked the funds to implement and support telehealth services.

By Anuja Vaidya

April 19, 2022 – The U.S. Department of Agriculture is awarding $43 million to support rural healthcare providers amid the ongoing COVID-19 pandemic, and many plan to use the funds to expand telehealth capabilities.

The Emergency Rural Health Care Grants were made available through the American Rescue Plan Act. In total, $475 million in grants have been earmarked to support rural hospitals and providers. In this round of funding, $43 million will be provided to 93 rural healthcare organizations and community groups across 22 states.

“USDA used an all-hands-on-deck approach to create the Emergency Rural Health Care Grants program to address a variety of immediate healthcare needs and services in rural communities,” said USDA Secretary Tom Vilsack in the press release.

Several grant awardees plan to use the funds to implement and enhance telehealth services. For example, Neosho Memorial Regional Medical Center in Chanute, Kansas, which is receiving $434,300, plans to use some of the funds to purchase and install telehealth infrastructure and upgrade information systems.

Another provider organization, Appleton Area Health in Minnesota, is planning to use part of its $174,300 grant to upgrade its telemedicine capabilities and replace hospital equipment. It also plans to install 28 flat-panel television monitors with cameras in clinic exam rooms and patient rooms.

McAlester Regional Healthcare Authority in Oklahoma, which is slated to receive $71,300, will use part of the money to implement a telehealth program at McAlester Regional Hospital. The organization plans to purchase 127 computers and hire a trainer/coordinator.

In addition to telehealth, rural providers will use the funds to increase staffing to administer COVID-19 vaccines and testing, establish nutrition assistance programs, and build or renovate facilities.

The next round of Emergency Rural Health Care Grants funding will be announced later this year.

Research shows that people living in rural areas were less likely to use telehealth during the COVID-19 pandemic, with some reporting lower telehealth availability than those who lived in urban areas.

One likely reason for this is the lack of access to broadband in many parts of the US. One estimate shows that at least 42 million Americans lacked access to terrestrial broadband internet in 2021.

Another probable reason for the lack of telehealth availability is that rural healthcare providers are in a precarious position, operationally and financially. Since the COVID-19 pandemic hit, 21 hospitals have closed in the US, and 40 percent of rural hospital operating margins are in the red, according to The Chartis Center for Rural Health.

A viewpoint article published in JAMA Health Forum last year pointed out some hurdles to telehealth adoption among rural providers. The authors cited lack of adequate cash flow, low patient volumes, and the telehealth reimbursement structure among the barriers.

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APRIL 13, 2022•STATEMENTS AND RELEASES

Vice President Harris to Host First-Ever Meeting with Cabinet Officials on Maternal Health

On Wednesday, April 13, 2022, during Black Maternal Health Week, Vice President Kamala Harris will convene a meeting with Cabinet Secretaries and agency leaders to discuss the Administration’s whole-of-government approach to addressing maternal mortality and morbidity. The Vice President will convene leaders across the federal government – including agencies that may not have historically taken a leading role addressing the maternal health crisis.
 
In December 2021, Vice President Harris convened the first-ever federal Maternal Health Day of Action, where she announced a historic Call to Action to improve health outcomes for parents and infants in the United States. This resulted in the Administration’s announcement of private sector and public sector investments. Ahead of the meeting with Cabinet officials, the Administration is following up with additional actions to address maternal health, and to combat the systemic inequities that lead to worse maternal outcomes for Black, Native American, and rural women.
 
New Announcements:

• 11 Additional States and D.C. Ask to Extend Medicaid and CHIP Coverage to a Full Year After Pregnancy under American Rescue Plan: The American Rescue Plan is working to make Medicaid and CHIP coverage for 12 months after pregnancy a reality for people across the country. The Vice President called on states to expand their postpartum coverage during her Call to Action in December.
  • The Centers for Medicare & Medicaid Services (CMS) has approved Louisiana, Virginia, New Jersey, and Illinois’ extension of Medicaid and CHIP coverage for 12 months after pregnancy on or before April 1, 2022. CMS is also working with another eleven states and the District of Columbia to extend postpartum coverage for a full year after pregnancy, including: California, Indiana, Kentucky, Maine, Michigan, Minnesota, Oregon, New Mexico, South Carolina, Tennessee, and West Virginia.  In addition, a number of other states have announced that they are working to extend Medicaid and CHIP coverage to 12 months after pregnancy, and CMS looks forward to working with those states.
  • In order to receive federal funds and to ensure consistency with federal standards, including those set by the American Rescue Plan, states must go through a formal process run by CMS. Medicaid covers more than 40 percent of births in the United States, and extending this coverage will bring the peace of mind of health coverage to parents and children during the vulnerable post-partum period. 
  • Based on HHS estimates, approximately 720,000 people would benefit if all states were to adopt the American Rescue Plan’s new option to extend post-partum Medicaid and CHIP coverage for a full 12 months.
• “Birthing-Friendly” Hospital Designation: CMS is proposing the “Birthing-Friendly” hospital designation to drive improvements in maternal health outcomes and maternal health equity. The “Birthing-Friendly” hospital designation would assist consumers in choosing hospitals that have demonstrated a commitment to maternal health. The Administration announced this new designation during the White House Maternal Health Day of Action Summit.
  • Initially, the designation would be awarded to hospitals based on attestation that the hospital has participated in maternity care quality improvement collaboratives and implemented best practices that advance health care quality, safety, and equity for pregnant and post-partum patients.
  • Data will be submitted by hospitals for the first time in May 2022, and CMS will post data for October to December 2021 in fall 2022. Criteria for the designation may be expanded in the future.
• Engaging the Health Care Industry to Improve Health Outcomes: In Summer 2022, CMS will convene health care industry stakeholders – including health care facilities, insurance companies, state officials and providers – to focus on industry commitments to improve health outcomes experienced by pregnant and postpartum people. CMS and experts will share best practices and commitments and request that health care industry leaders make commitments to advance maternal health.
• Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Programs: The Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced approximately $16 million to strengthen Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Programs through seven awards supporting eight states.
  • These awards will advance data and technology innovations to support positive maternal and child health outcomes in states and communities, and focus on addressing health disparities.
• State Maternal Health Innovation and Implementation (State MHI) Program: State MHI supports state-level development and implementation of proven strategies to improve maternal health and address maternal health disparities. The new funding, $9 million, will continue to build state capacity to deliver high-quality maternity care services and provide training for maternal care clinicians. It also adds a component to enhance the quality of state-level maternal health data through better collection, reporting and analysis. The program will fund up to nine cooperative agreements, and each will receive up to $1 million over five years.
• Maternal Health Best Practices: HHS, through the Health Resources and Services Administration (HRSA), is also, on telehealth.hhs.gov, posting a new Maternal Health Best Practice Guide for providers to incorporate telehealth for prenatal and postpartum care, and monitoring within high-risk pregnancy. Through remote patient monitoring, screening and treatment for postpartum depression, and lactation consulting, maternal telehealth can help reduce barriers to access to critical care for mothers before, during and after a pregnancy.

Previous Actions Announced since the Vice President’s Call to Action in December

• Investing in Doulas: HHS announced the availability of $4.5 million for hiring, training, certifying, and compensating community-based doulas in areas with high rates of adverse maternal and infant health outcomes, doubling the number of Healthy Start doula programs nationwide.
• Title X: HHS restored access to Title X family planning services nationwide to fill service gaps caused by more than a quarter of Title X providers withdrawing from the program over the past two and a half years in response to the previous administration’s Title X rule. HHS awarded $256.6 million in grant funding to support 76 grantees to deliver equitable, affordable, client-centered, and high-quality family planning services.
• FY23 Budget Request: The President’s budget includes $470  million to: reduce maternal mortality and morbidity rates; expand maternal health initiatives in rural communities; implement implicit bias training for healthcare providers; create pregnancy medical home demonstration projects; and address the highest rates of perinatal health disparities, including by supporting the perinatal health workforce.

Additional Background

• As Vice President, Kamala Harris has worked closely with President Biden and other leaders in the Administration to improve outcomes for Black women and their families.
  • The White House released a Presidential Proclamation to mark Black Maternal Health Week in 2021 and 2022.
  • In December 2021, the Vice President led a Maternal Health Day of Action Summit, noting the urgent need to address this crisis.
    • At the Summit, the Vice President announced guidance to help states provide 12 months of continuous postpartum coverage through their Medicaid programs, up from 60 days; a new HHS report showing the impact of state extensions of Medicaid postpartum coverage to 12 months; and CMS’s plan to propose the establishment of a “Birthing-Friendly” hospital designation. She also announced that more than 20 companies and nonprofits have pledged to invest over $150 million and take other critical actions to address the maternal health crisis.
  • In April 2021, the Vice President hosted a roundtable on Black Maternal Health with Domestic Policy Advisor Ambassador Susan Rice. She was joined by women who shared their experiences with complications from pregnancy, childbirth, and postpartum as well as their work in advocacy and research, highlighting the disparities that Black women face in maternal health.

• The Omnibus spending bill passed in March and signed by the President includes both the Maternal Health Quality Improvement Act and an expansion of the Rural Maternal and Obstetric Modernization of Services (Rural MOMS) program. 
  • These foundational bills authorize and improve programs to address the maternal mortality crisis in this country and build on current funding at the Centers for Disease Control & Prevention (CDC) and Health Resources and Services Administration (HRSA) to reduce maternal morbidity and mortality.
• Last fall, the Administration released the first-ever National Strategy on Gender Equity and Equality, which includes its vision to strengthen health care and  women’ health, including through addressing the maternal mortality crisis in the United States and abroad.
• As a Senator, Vice President Harris was a champion on the issue of maternal health. She brought racial disparities in maternal mortality, particularly for Black women, to the forefront legislatively, increasing awareness among her colleagues and leading to a broader discussion of racial disparities across other health issues.
  • She convened roundtables, lifted up local organizations that are focused on the issue, and ensured that initiatives on maternal health included references to racial disparities and relevant solutions.

She introduced several bills in the Senate specifically targeted to addressing racial disparities in maternal mortality, including the Maternal CARE Act and the Black Maternal Health Momnibus Act.

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The Biden Administration is awarding nearly $1 billion in American Rescue Plan funding through the HRSA to about 1,300 health centers across the country for capital improvements, including telehealth expansion.

By Eric Wicklund

September 28, 2021 – The Biden Administration is shelling out almost $1 billion in American Rescue Plan funding to health centers in every state to support a wide range of projects, including telehealth expansion.

In all, $954,255,430 will be awarded through the Health and Human Services Department’s Health Resources and Services Administration (HRSA) to support capital improvement projects at 1,292 Health Center Program-funded sites In every state as well as Washington DC and US territories.

Alongside telehealth services, the money is earmarked for COVID-19 testing, treatment and vaccination and advancing health equity initiatives in underserved regions.

“Health centers are lifelines for many of our most vulnerable families across the country, especially amidst the pandemic,” HHS Secretary Xavier Becerra said in a press release issued this morning. “Thanks to American Rescue Plan funds, we’re modernizing facilities across the country to better meet the most pressing public health challenges associated with COVID-19. This historic investment means we get to expand access to care for COVID-19 testing, treatment and vaccination – all with an eye towards advancing equity.”

Officials said the money is earmarked for health centers that serve medically underserved and other vulnerable populations and communities, many of which have been hit hard by the pandemic and have struggled to maintain access to healthcare services.

While the federal government is putting a lot of rescue plan money into these health centers and other sites that target underserved populations, critics have pointed out that the funding will help them set up connected health programs but it won’t assure their sustainability.

Telehealth advocates are lobbying the Centers for Medicare & Medicaid Services to improve coverage for and access to telehealth and remote patient monitoring services through the proposed 2022 Physician Fee Schedule. And Congress is under pressure to enact a long-term telehealth policy that supports continued adoption and expansion past the public health emergency put into place for the pandemic.

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UNITED STATES — The United States Department of Agriculture is making up to $500 million available in grants to help rural healthcare facilities, tribes and communities expand access to COVID-19 vaccines, healthcare services and nutrition assistance.

President Biden’s comprehensive plan to recover the economy and deliver relief to the American people is changing the course of the pandemic and providing immediate relief to millions of households, growing the economy and addressing the stark, intergenerational inequities that have worsened in the wake of COVID-19.

“Under the leadership of President Biden and Vice President Harris, USDA is playing a critical role to help rural America build back better and equitably as the nation continues to respond to the pandemic,” Agriculture Secretary Tom Vilsack said. “Through the Emergency Rural Health Care Grants, USDA will help rural hospitals and local communities increase access to COVID-19 vaccines and testing, medical supplies, telehealth, and food assistance, and support the construction or renovation of rural healthcare facilities. These investments will also help improve the long-term viability of rural healthcare providers across the nation.”

Applicants may apply for two types of assistance: Recovery Grants and Impact Grants.

The Biden-Harris administration is making Recovery Grants available to help public bodies, nonprofit organizations and tribes provide immediate COVID-19 relief to support rural hospitals, healthcare clinics and local communities.

These funds may be used to increase COVID-19 vaccine distribution and telehealth capabilities; purchase medical supplies; replace revenue lost during the pandemic; build and rehabilitate temporary or permanent structures for healthcare services; support staffing needs for vaccine administration and testing; and support facility and operations expenses associated with food banks and food distribution facilities.

Recovery Grant applications will be accepted on a continual basis until funds are expended.  

The administration is also making Impact Grants available to help regional partnerships, public bodies, nonprofits and tribes solve regional rural healthcare problems and build a stronger, more sustainable rural healthcare system in response to the pandemic.

USDA encourages applicants to plan and implement strategies to: develop healthcare systems that offer a blend of behavioral care, primary care and other medical services; support healthcare as an anchor institution in small communities; and expand telehealth, electronic health data sharing, workforce development, transportation, paramedicine, obstetrics, behavioral health, farmworker healthcare and cooperative home care.

For Montana, Impact Grant applications must be submitted to the Montana USDA Rural Development State Office by 4 p.m. MDT on Oct. 12.

 USDA encourages potential applicants to review the application guide at www.rd.usda.gov/erhc. USDA Rural Development is prioritizing projects that will support key priorities under the Biden-Harris administration to help rural America build back better and stronger. Key priorities include combatting the COVID-19 pandemic; addressing the impacts of climate change; and advancing equity in rural America. For more information, visit www.rd.usda.gov/priority-points.

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Klobuchar, Smith Announce USDA Grant Program to Support Health Care in Rural Communities

Klobuchar and Smith held event with U.S. Agriculture Secretary Vilsack to announce the program

WASHINGTON – U.S. Senators Amy Klobuchar (D-MN) and Tina Smith (D-MN) joined U.S. Agriculture Secretary Tom Vilsack to announce that the U.S. Department of Agriculture (USDA) will make significant funding available through Emergency Rural Health Care grants to help rural health care facilities, tribes, and communities expand access to coronavirus vaccines, health care services, and nutrition assistance.

“Strengthening access to quality health care in rural areas is crucial to the success and prosperity of our state,” said Sen. Klobuchar. “This federal funding will make a big difference by providing medical equipment, telehealth services, food assistance, and coronavirus vaccines to those in our rural communities. As we round the corner of this pandemic, I’ll continue working to ensure all Minnesotans can receive the care and services they need.”

“This is how we advance our commitment to improving access to health care in rural areas. With this new funding, rural health care providers will be able to develop their infrastructure, and contribute to a resilient community,” said Sen. Smith, a member of both the Senate Health and Ag Committees and Co-Chair of the bipartisan Senate Rural Health Caucus. “I look forward to continuing to work with Secretary Vilsack and the Biden Administration to pursue a comprehensive investment in rural communities.”

“Under the leadership of President Biden and Vice President Harris, USDA is playing a critical role to help rural America build back better and equitably as the nation continues to respond to the pandemic,” said U.S. Agriculture Secretary Vilsack. “Through the Emergency Rural Health Care Grants, USDA will help rural hospitals and local communities increase access to COVID-19 vaccines and testing, medical supplies, telehealth, and food assistance, and support construction or renovation of rural health care facilities. These investments will also help improve the long-term viability of rural health care providers across the nation.”

Beginning today, applicants may apply for two types of assistance: Recovery Grants and Impact Grants.

Recovery Grants are available to help public bodies, nonprofit organizations, and tribes provide immediate coronavirus relief to support rural hospitals, health care clinics, and local communities. These funds may be used to increase coronavirus vaccine distribution and telehealth capabilities, purchase medical supplies, replace revenue lost during the pandemic, build and rehabilitate temporary or permanent structures for health care services, support staffing needs for vaccine administration and testing, and support facility and operations expenses associated with food banks and food distribution facilities. Recovery Grant applications will be accepted on a continual basis until funds are expended.

Impact Grants are also available to help regional partnerships, public bodies, nonprofits, and tribes solve regional rural health care problems and build a stronger, more sustainable rural health care system in response to the pandemic. Impact Grant applications must be submitted to your local USDA Rural Development State Office by 4:00 p.m. local time on October 12, 2021. 

Throughout the coronavirus pandemic, Sens. Klobuchar and Smith have worked to improve and increase access to health care in rural communities.

In December, Sen. Klobuchar fought to put in place a federal distribution strategy to ensure health care systems and pharmacies in rural communities would be able to distribute and administer coronavirus vaccines. She has also advocated to increase the number of health care providers in rural communities, and in May introduced legislation to allow international doctors to remain in the U.S. upon completing their residency under the condition that they practice in areas experiencing doctor shortages.

As Chair of the Rural Development Subcommittee and Co-Chair of the Senate Rural Health Caucus, Sen. Smith has made it her goal to highlight the contributions of rural places in Washington. She also understands that small towns and rural communities face unique challenges, and she has long worked to address these challenges. Sen. Smith successfully worked to secure $500 million for the Community Facilities Program to help rural hospitals respond to the COVID-19 pandemic and strengthen their operations moving forward, including by expanding telehealth access, strengthening the health care workforce, and expanding nutrition assistance. Sen. Smith has also pushed for advancing telehealth during and beyond the COVID-19 public health emergency period. Sen. Smith worked on a bipartisan measure—enacted as part of the CARES Act—to reform rural health grants, and she worked across the aisle on her Helping Rural Hospitals Hit by COVID-19 Act to help ease the financial strain faced by rural hospitals as they have responded to the COVID-19 pandemic. This provision was enacted as part of the American Rescue Plan Act.

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In the early morning of Feb. 27, 2021, the U.S. House of Representatives narrowly passed H.R. 1319, the American Rescue Plan Act of 2021, by a 219-212 vote. Two Democrats joined with a united Republican caucus to oppose the bill. House Democratic leadership introduced and passed the American Rescue Plan the same week the United States announced its 500,000th death from COVID-19.

President Joe Biden requested the American Rescue Plan’s $1.9 trillion in spending to develop a national vaccination program; increase COVID-19 testing, tracing and treatment; change employment regulations, including the federal minimum wage; and address the negative financial impacts of the COVID-19 pandemic. The bill includes financial relief to state, local and tribal governments, as well as extensions to enhanced unemployment benefits, certain debt collection relief and direct cash payments to households.

The House action followed a ruling by the Senate parliamentarian that could mean the Senate will not include some provisions of the House bill. In the Senate, using budget reconciliation to pass legislation subjects that legislation to the Byrd Rule. Named for the late Sen. Robert Byrd (D-W.V.), the rule allows provisions that do not have a direct budgetary impact to be struck from legislation. Reconciliation allows the Senate to pass legislation with a simple majority rather than the filibuster-proof threshold of 60 votes. This means, because of the 50-50 partisan split in the Senate, all Democratic senators must be united to pass the legislation, with Vice President Kamala Harris serving as the tie breaker.

On Feb. 25, the Senate parliamentarian ruled before the Senate considering the legislation that the House’s provision for a phased increase to the federal minimum wage to $15 per hour did not pass the Byrd Rule test. There may be other provisions that, if the Byrd Rule is raised during debate, may also be struck. Since the 1980s, reconciliation has largely been limited to mandatory programs and taxes. Under some interpretations of the Byrd Rule criteria, funding for education, vaccines, testing and public health activities as well as child care could fall under the Byrd Rule test. However, if no one raises the point of order during debate, no ruling occurs. Should provisions be struck from the House-passed legislation, the House would have to vote on what the Senate passes. The Democratic leadership’s target date for getting the legislation to President Biden’s desk is March 14.

Discussed below are 15 provisions included in the legislation, as it shifts to the Senate, that healthcare providers should understand:

1. Funds COVID-19 Vaccine Activities. The American Rescue Plan allocates significant additional funding for COVID-19 vaccine activities. First, it provides $7.5 billion to the Centers for Disease Control and Prevention (CDC) to plan, prepare for, promote, distribute, administer, monitor and track COVID-19 vaccines. Key aims for this funding include distributing vaccines, establishing community vaccination centers and mobile vaccine units, and communicating with the public about how to receive vaccines. In addition to the funding noted above, the legislation provides $1 billion to the U.S. Department of Health and Human Services (HHS) for vaccine confidence programs designed to increase national vaccination rates.

The legislation provides $6.05 billion for necessary expenses related to research, development, manufacturing, production and purchase of vaccines. Separately, the American Rescue Plan provides $10 billion under the Defense Production Act for medical supplies and equipment, including personal protective equipment (PPE), and for responding to future pathogens with the potential to create a public health emergency. Finally, the legislation allocates $500 million to the Food and Drug Administration for evaluation, oversight and facilitation of vaccine performance and manufacturing.

2. Funds COVID-19 Testing, Contact Tracing and Mitigation Activities. The American Rescue Plan also focuses significant funds on continued COVID-19 testing and mitigation efforts — specifically, $47.8 billion to detect, diagnose, trace and monitor COVID-19 infections and related strategies to mitigate the spread of COVID-19. HHS was directed to use the funds to take actions such as: implementing a national testing strategy, funding health departments’ efforts related to COVID-19 testing supplies, and enhancing data sharing related to COVID-19 testing.

The legislation also allocates $1.75 billion to expand activities and workforce related to genomic sequencing, analytics and disease surveillance. Next, the bill provides money to combat COVID-19 and other emerging infectious disease threats globally, including global health security, disease detection and response, protection immunization and coordination. There is some ambiguity on the final dollars approved here for global health due to the House process, but the draft legislation presented to the final committee before House passage included $750 million. Finally, the legislation provides $500 million to the CDC to support public health data surveillance and analytics infrastructure modernization initiatives and establish, expand and maintain efforts to modernize the U.S. disease warning system to forecast and track hot spots for COVID-19 and emerging biological threats. Similar provisions were included in the House-passed Health and Economic Recovery Omnibus Emergency Solutions Act (HEROES Act).

3. Expands Health Insurance Access Through COBRA Continuation Coverage. The American Rescue Plan allows individuals eligible for COBRA coverage to maintain their employer-sponsored coverage after a layoff, reduction in hours or furlough, by paying only 15 percent of premiums through Sept. 30, 2021. The HEROES Act proposed to provide full coverage for such individuals throughout 2020, but that provision did not pass in the Senate. The legislation provides special extended election periods and special enrollment provisions allowing the opportunity for individuals previously declined COBRA continuation coverage or who had such coverage and discontinued the coverage prior to the enactment of the law. Group health plans are required to provide notices of these coverage opportunities.

Finally, the legislation provides a refundable tax credit for employers and group health plans to reimburse the full amount of COBRA coverage premiums. Other coverage-related expansions include spending on health insurance exchanges and spending on federal employees and maritime employees diagnosed with COVID-19 before Jan. 30, 2023, with such illness presumed to be a work-related illness for wage loss compensation, or longshore and harbor workers benefits,

4. Funds Public Health Workforce and Mental Health Training. The American Rescue Plan includes $7.66 billion to strengthen the nation’s workforce at public health departments at the state, local and territorial levels. A recipient public health department can use received funds for personnel costs, PPE, certain data-related and other types of technology, related administrative costs, reporting requirement costs and sub-awards to local health departments. In particular, the legislation defines eligible personnel costs broadly to include costs necessary to recruit, hire and train people to “serve as case investigators, contact tracers, social support specialists, community health workers, public health nurses, disease intervention specialists, epidemiologists, program managers, laboratory personnel, informaticians, communication and policy experts, and any other positions as may be required to prevent, prepare for, and respond to COVID-19” at public health departments and certain nonprofit organizations.

An additional $100 million is provided for the nation’s Medical Reserve Corps, which supplies volunteers in public health emergencies, plus $200 million for nursing loan repayment programs. An added $330 million is allocated for teaching health centers that operate graduate medical education programs. Finally, $80 million is provided for mental and behavioral health training and $100 million would fund a Behavioral Health Workforce Education and Training Program. All of this funding comes after the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) provided significant funding for the healthcare workforce.

5. Increases Funding for Community Health Centers. The American Rescue Plan provides an additional $7.6 billion to health centers, federally qualified health centers and the Papa Ola Lokahi (which seeks to improve the health status and wellbeing of Native Hawaiians and their families) and to other entities named in the Native Hawaiian Health Care Improvement Act. The awards under this provision must be used for COVID-19-related purposes. These purposes include promoting, distributing and administering the COVID-19 vaccine, as well as detecting COVID-19 infection, tracing and mitigation efforts, and developing a workforce necessary to respond to COVID-19. The centers may use awards to acquire equipment and supplies for mobile testing or vaccinations. Finally, awards can be used to “modify, enhance, and expand health care services and infrastructure” and to work within communities for COVID-19 outreach and education. This funding comes after funding extensions for health centers in the year-end omnibus Consolidated Appropriations Act, 2021 (H.R. 133), and in the Continuing Appropriations Act, 2021 and Other Extensions Act, and funding increases in the CARES Act.

6. Provides Emergency Rural Development Grants for Rural Healthcare. The American Rescue Plan provides $500 million to the secretary of the Department of Agriculture until Sept. 30, 2023, for needs-based grants to facilities that primarily serve rural areas, and that target and bolster certain aspects of the COVID-19 response efforts. Specifically, funds from the grants may be used to increase vaccine distribution capacity, provide drugs or medical supplies to increase medical surge capacity, increase telehealth capabilities, construct temporary or permanent structures to provide healthcare services, and support staffing needs for vaccine administration and testing. Additionally, the funds may be used to reimburse expenses and lost revenue due to the COVID-19 pandemic incurred prior to the awarding of a grant, along with any other efforts determined to be critical to address the COVID-19 pandemic and approved by the secretary of the Department of Agriculture.

7. Funds Indian Health Services. The American Rescue Plan includes $5.4 billion to support the activities of Indian Health Services (IHS). These funds include $2 billion for lost reimbursements from third-party payors to IHS during the pandemic; $500 million for the Purchased/Referred Care program; $140 million for information technology, telehealth and electronic health records infrastructure; $84 million for the Urban Indian Health Programs; $600 million for tracking COVID-19 vaccines; $1.5 billion for tracing infections; $240 million for public health workforce supporting American Indian health; and $420 million for mental and behavioral health. An additional $600 million will be available for IHS health facility improvements to respond to COVID-19. These funding programs are in addition to $1 billion provided in the CARES Act and more than the $2.1 billion proposed in the House-passed HEROES Act.

8. Increases Spending on Mental Health Services. The American Rescue Plan provides an additional $3.5 billion for block grants to states, with half allocated for the Community Mental Health Services Block Grant program and the other half for the Substance Abuse Prevention Treatment Block Grant program. These block grant programs provide funding to all U.S. states and territories for programs targeting those with serious mental illnesses and to prevent and treat substance abuse. This spending is a substantial increase to these block grants, as the fiscal year 2020 amounts for these two programs were $722.5 million and $1.85 billion, respectively, and recipient states and territories have until Sept. 30, 2025, to spend the funds.

The legislation also provides funding for a variety of mental and behavioral health-related programs, including $20 million for an awareness campaign focused on healthcare professionals; $40 million for healthcare workforce mental and behavioral care; $30 million for community-based overdose prevention programs, syringe service programs and other harm reduction programs; and $50 million for community behavioral health needs worsened by the COVID-19 pandemic. These funding programs are in addition to $6 billion to the Substance Abuse and Mental Health Services Administration (SAMHSA) and $7.5 billion to the Health Resources and Services Administration for substance abuse treatment in H.R. 133 and proposed in the House-passed HEROES Act.

9. Enhances Medicaid Funding for Community-Based Mobile Crisis Intervention Services. The American Rescue Plan provides a Medicaid federal medical assistance percentage (FMAP) matching payment to state Medicaid programs equal to 85 percent of the cost for community-based mobile crisis intervention services furnished through bundled payments for a three-year period beginning one year from enactment. Such mobile crisis team services have been supported by SAMHSA grant programs and are intended to provide interventions to individuals with mental health and substance abuse needs where the individual is experiencing a crisis, outside a hospital or health facility. Such services are team-based, with at least one behavioral healthcare professional and members are trained in providing trauma-informed care. They are able to quickly screen, stabilize and coordinate healthcare services for the individual, and are encouraged to partner with emergency medical services and other healthcare facilities in a community. The American Rescue Plan also provides $15 million for planning grants to develop such offerings under the respective state Medicaid plan.

10. Mandates and Funds Medicaid and CHIP Coverage for COVID-19 Vaccines. The American Rescue Plan requires state Medicaid and CHIP plans to cover testing and treatment for COVID-19 for Medicaid and CHIP beneficiaries with an FMAP rate of 100 percent through one year after the end of the public health emergency, and adjustments for CHIP state allotments. In addition, the legislation allows state Medicaid plans to cover eligible uninsured groups, including specialized and preventative therapies for individuals diagnosed with or presumed to have COVID-19. Additionally, COVID-19 vaccines and treatments must be made available for certain conditions that might be complicated by COVID-19, such as cancer or pregnancy.

Coverage must begin on the enactment date of the American Rescue Plan and end on the last day of the first quarter that begins one year after the end of the emergency period. State Medicaid and CHIP plans will not be allowed to require beneficiary cost sharing for COVID-19 vaccines or treatment of a condition that may seriously complicate the treatment of COVID-19. The legislation also allows outpatient drugs used for COVID-19 prevention or treatment to be included in the Medicaid Drug Rebate Program.

11. Modifies Medicaid and CHIP Coverage for Pregnant and Postpartum Women. The American Rescue Plan allows state Medicaid and CHIP plans to provide pregnancy- and postpartum-related medical assistance coverage to eligible beneficiaries, including low-income children covered under CHIP, for seven years. Full benefits would be available to women during pregnancy and throughout the 12-month postpartum period, or up to a year after the last day of her pregnancy. If the state selects this option for its Medicaid program, it must provide it under its CHIP program.

12. Increases Medicaid Funding for Newly Expanded State Coverage and Other Support for State Medicaid Programs. The American Rescue Plan seeks to encourage states to expand their Medicaid programs to the uninsured by increasing the FMAP for such expansion by 5 percent for two years. Effectively, this would increase the FMAP for expansion to newly eligible beneficiaries in new expansion states after enactment to 95 percent, closer to the Affordable Care Act’s original 100 percent match. If expanded, state Medicaid plans must cover individuals whose income does not exceed 133 percent of the poverty line. The FMAP increase will not apply to disproportionate-share hospital payments.

Additionally, the American Rescue Plan extends the 100 percent FMAP rate for services provided at Urban Indian Health Organizations and Native Hawaiian Health Care Systems for two years. The legislation also increases the FMAP by 7.35 percent for state Medicaid programs from home and community-based services that are provided between April 1, 2021, and March 31, 2022 (not to exceed 95 percent). State eligibility for FMAP assistance requires states to implement certain activities, which include enhancing, expanding and strengthening home and community-based services under the state’s Medicaid program. These FMAP increases are in addition to amounts provided in the Families First Coronavirus Response Act to state Medicaid plans.

13. Increases Veterans Affairs Care Funding. The American Rescue Plan provides $13.48 billion for healthcare services and related support to eligible veterans under the Department of Veterans Affairs (VA) programs through Sept. 30, 2023. This funding helps to cover the loss of health insurance for many veterans and also to sustain CARES Act staffing and service-level expansions. The VA will have wide discretion on spending such funds, including for facility improvements, suicide prevention and other mental health services, telehealth and other healthcare-related uses. The VA will waive up to $2 billion in copayments from April 6, 2020, through Sept. 30, 2021, and must reimburse veterans who paid copayments or other cost sharing during this period. Finally, the legislation provides $750 million for state veterans’ homes for upgrades related to safety and one-time emergency payments to support operations for enhanced treatments, cleaning and supplies during the COVID-19 pandemic.

14. Supports Skilled Nursing Facilities Responding to COVID-19. The American Rescue Plan provides $200 million to HHS for infection control efforts through the development and dissemination of protocols related to COVID-19 prevention and mitigation in skilled nursing facilities (SNFs). Further, the legislation provides another $250 million for states to establish and implement strike teams to assist SNFs with clinical care, infection control or staffing during the COVID-19 emergency period. Each state’s strike team would be deployed to SNFs in the state with diagnosed or suspected COVID-19 cases among residents or staff, to respond to the situation. The strike teams are similar to a proposal in the House-passed HEROES Act that would have created federal strike teams.

15. Supports OIG Oversight of the Provider Relief Fund. While a smaller appropriation, the American Rescue Plan provides $5 million to the HHS Office of Inspector General (OIG) for oversight activities with respect to the public health and social services emergency fund (the Provider Relief Fund). The Provider Relief Fund was created through congressional appropriations now totaling $178 billion to reimburse healthcare providers’ eligible expenses and lost revenues attributable to COVID-19. HHS developed the Provider Relief Fund through multiple rounds of payment distributions, including both General Distributions and Targeted Distributions to specific provider categories. In late February 2021, the U.S. Department of Justice announced its first Provider Relief Fund-related criminal indictment. With the American Rescue Plan funding, OIG is likely to increase its planned efforts to audit and review Provider Relief Fund spending.

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On March 10, 2021, Congress finalized and passed the American Rescue Plan of 2021 (ARP), the latest COVID-19 relief package that largely tracks President Biden’s initial $1.9 trillion proposal. The ARP extends unemployment insurance benefits and provides direct $1,400 stimulus payments to qualifying Americans, but it also makes several important health-policy-related changes. These include providing funding for vaccine distribution and testing to combat the COVID-19 pandemic, making policy adjustments to the Medicaid program, facilitating health insurance coverage and providing more money for healthcare providers. The final bill also makes two narrowly focused technical Medicare payment changes.

In developing and finalizing the bill, Democrats used the budget reconciliation process to pass the bill with only Democratic support. This process limited what could be included. The version that was signed into law ultimately removed a provision to increase the federal minimum wage to $15 per hour because it failed to meet reconciliation rules.

This summary highlights notable health policy provisions of the final bill.

COVID-19 RELIEF

PUBLIC HEALTH FUNDING

Background: Like previous COVID-19 relief packages, this bill includes funding for COVID-19 vaccine distribution, testing and contact tracing, and support for healthcare workforce expansion and public health initiatives.

Provisions: The ARP provides funding to support vaccination and treatment, including $7.5 billion directed to the Centers for Disease Control and Prevention to plan, prepare for, promote, distribute, administer, monitor and track COVID-19 vaccines.

The bill also provides support for workforce initiatives, including $7.66 billion to state, local and territorial public health departments to hire staff and procure equipment, technology and other supplies to support public health efforts. The legislation includes $100 million for the Medical Reserve Corps, $800 million for the National Health Service Corps, $200 million for the Nurse Corps and $330 million for teaching health centers that operate graduate medical education.

The bill allocates $47.8 billion to continue implementation of an evidence-based national COVID-19 testing strategy, and directs $1.75 billion to support genomic sequencing and surveillance initiatives.

PROVIDER RELIEF LOOK-A-LIKE FUND FOR RURAL PROVIDERS

Background: The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed in March 2020, established the Provider Relief Fund (PRF) to reimburse providers for COVID-19-related expenses and lost revenues. To date, $178 billion has been appropriated to the fund. Approximately $153 billion has been allocated to providers, and about $25 billion remains to be allocated. This $25 billion does not account for PRF distributions that have been or may yet be returned to the US Department of Health and Human Services (HHS) by recipients that rejected the financial support, so the actual amount remaining could be larger. The remaining funds are subject to spending limitations for providers for the second half of 2020 and the first quarter of 2021 due to provisions in the appropriations bill passed at the end of 2020.

Provision: Despite stakeholder requests to add as much as $35 billion to the general PRF, the ARP provides only $8.5 billion, and does so through a look-a-like PRF specifically for rural entities serving Medicare and Medicaid beneficiaries. Congress took this unconventional approach to overcome limitations imposed by the reconciliation process. HHS will allocate this funding to eligible rural providers for healthcare-related expenses and lost revenues attributable to COVID-19 not reimbursed (or obligated to be reimbursed) by other sources. Although these funds are not directed to the existing PRF, the ARP’s language largely aligns with previous PRF appropriations language. For example, the ARP definitions of lost revenues and healthcare-related expenses attributable to COVID-19 are similar to those used in the Consolidated Appropriations Act 2021 appropriating additional funds to the PRF, and are similar to HHS’s PRF guidance documents defining those terms. Although it appears that Congress intends for these funds to be consistent with the PRF, it is unclear whether HHS will treat the $8.5 billion in a completely consistent manner.

The ARP funds are only available to rural providers or suppliers, which the bill defines as those that (1) are located in a rural area, as defined in section 1886(d)(2)(D) of the Social Security Act (SSA)); (2) are treated as being located in a rural area under SSA section 1886(d)(8)(E); (3) are located in “another area” (as defined by the HHS Secretary) that serves rural patients; (4) are a Rural Health Clinic (as defined by SSA section 1861(aa)(2)); or (5) furnish home health, hospice, or long-term services or supports in an individual’s home located in a rural area (as defined in SSA section 1886(d)(2)(D)). The HHS Secretary also has authority to include other rural providers or suppliers as eligible. Unlike the PRF’s targeted rural distributions, which were distributed directly to select providers by HHS, rural providers and suppliers seeking the ARP funds must submit an application to HHS. This definition of “rural” captures traditionally rural providers and suppliers, but also is broad enough to potentially render eligible a number of urban providers and suppliers that have undergone redesignation to be considered rural, or that may be in urban areas, but treat rural patient populations. And that is before accounting for the Secretary’s additional broad authority to define rural for eligibility purposes.

FUNDING FOR MENTAL HEALTH AND SUBSTANCE USE DISORDERS

Background: Mental health remains a serious concern during the COVID-19 pandemic. Studies have shown increases in suicide, opioid addiction and other mental health crises.

Provision: The bill allocates $3 billion for block grants to state and local government entities to address mental health and substance use disorders, as well as additional funding for behavioral health workforce education and community-based behavioral health services.

FUNDING FOR STATE, LOCAL AND TRIBAL GOVERNMENTS

Background: The CARES Act established a $150 billion Coronavirus Relief Fund for state, local and tribal governments. The federal relief funds are restricted and can be used only on expenses that directly relate to COVID-19. Under the CARES Act, recipients had to use this money by December 31, 2020. The Consolidated Appropriations Act, 2021, enacted in December 2020, extended the time period during which states, tribal governments and localities could use the original CARES Act funding to December 31, 2021.

Provision: The ARP provides an additional $350 billion to states, localities and tribes. Of those funds, state, territory and tribal governments will receive $220 billion. Local governments will receive approximately $130 billion. The ARP also extends the time period for use until December 31, 2024. The funding can be used for public health efforts responding to the COVID-19 pandemic, and for efforts to address the pandemic’s economic impact, including assistance to households, small businesses and nonprofits, or aid to impacted industries such as tourism, travel and hospitality. It can also be used to make investments in public health infrastructure and to respond to decreases in revenue due to the COVID-19 pandemic.

RURAL HEALTHCARE GRANTS

Background: The COVID-19 pandemic has financially affected rural providers in particular. While a portion of the PRF was allocated specifically to providers in rural areas, many believe more support is needed.

Provision: The ARP provides $500 million through the US Department of Agriculture to award grants to eligible entities, including public municipalities and counties, nonprofit organizations and tribes in rural areas. These grants can be used to cover COVID-19-related expenses and to increase capacity and telehealth capabilities.

MEDICAID AND CHIP

MANDATORY COVERAGE OF COVID-19 VACCINATION WITHOUT COST SHARING

Background: The Families First Coronavirus Response Act, the first COVID-19 relief package enacted in 2020, allows states to receive an enhanced Medicaid federal medical assistance percentage (FMAP) if they meet certain conditions. These conditions include covering COVID-19 testing services and treatment, such as vaccines and their administration, for Medicaid enrollees without cost sharing. The Trump Administration interim final rule with comment period, “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” excluded from this requirement individuals enrolled in special limited coverage groups and individuals enrolled through Section 1115 demonstration waivers that cover a narrow set of benefits.

Provision: The ARP requires state Medicaid programs and the Children’s Health Insurance Program (CHIP) to provide coverage, without cost sharing, for treatment or prevention of COVID-19 for one year after the end of the public health emergency (PHE), while raising the FMAP to 100% for payments to states for administering vaccines for the same period. If a state chooses to implement an option under Medicaid to provide COVID-19 testing for uninsured individuals, the law also extends the requirement to provide treatment and prevention to those individuals without requiring cost sharing for one year after the end of the PHE.

COVERAGE OF PREGNANT AND POSTPARTUM WOMEN

Background: For 60 days after the birth of a child, states must provide Medicaid coverage to women whose income does not exceed 138% of the federal poverty level (FPL), and states have the option extend this 60-days coverage to individuals with higher income levels. According to Kaiser Family Foundation, 48 states and the District of Columbia exercise that option under current law to provide Medicaid coverage to pregnant women whose income is above 138% of FPL. Of these, 15 states extend coverage to women between 139% and 199% the FPL, 30 states extend coverage to women between 200% and 299% of the FPL, and five states extend coverage to women between 300% and 380% of the FPL. States also can provide pregnancy-related services to women under CHIP, but they may only provide postpartum services to women who, if not for their income, would otherwise be eligible for coverage under Medicaid.

States can provide CHIP coverage to eligible women during pregnancy and for 60 days after the birth of a child. CHIP cannot be used to replace existing Medicaid coverage for pregnant women. To cover pregnant women under CHIP, states must provide, at a minimum, Medicaid coverage to women whose income is up to 185% of the FPL. 

Provision: The ARP gives states the option to extend health coverage for women enrolled in Medicaid or CHIP for up to 12 months after the birth of a child. This option will be available for five years beginning on the first day of the first fiscal year quarter after the enactment of ARP.

INCREASED FMAP TO INCENTIVIZE STATES TO EXPAND MEDICAID

Background: The Affordable Care Act (ACA) required the federal government to pay 100% of state Medicaid costs for the expansion population through 2016, after which time the matching rate began phasing down to 90% in 2020 and thereafter. Currently, 38 states and the District of Columbia have adopted Medicaid expansion consistent with the ACA.

Provision: The ARP incentivizes non-expansion states to expand Medicaid eligibility for all adults with income up to 138% of the FPL by providing a five-percentage-point increase in the Medicaid FMAP for eight calendar quarters. This FMAP increase is only available to states that have not yet expanded coverage and have not yet started paying for the expansion population prior to the enactment of the law. The FMAP bump applies to services provided to traditional eligibility groups and excludes certain payments, such as disproportionate share hospital (DSH) payments and Medicaid allotments to territories. This increase in FMAP likely will not be sufficient incentive for non-expansion states to expand Medicaid. However, ballot initiatives, a change in the governor’s mansion, or change in control of the state legislature could lead additional states to Medicaid expansion.

SUNSET OF LIMIT ON MAXIMUM REBATE AMOUNT FOR SINGLE SOURCE DRUGS, INNOVATOR MULTIPLE SOURCE DRUG

Background: Drug manufacturers are required to pay Medicaid a rebate on all covered outpatient drugs. The rebate amount is determined by statute using two formulas that include a basic rebate with separate calculations for brand and generic drugs. There is also an additional inflationary rebate that reflects differences in growth between the average manufacturer prices and the consumer price index. The total rebate amount is capped at 100% of the average manufacturer price.

Provision: The ARP eliminates the cap on the total rebate amount starting January 1, 2024.

TEMPORARY ENHANCED FMAP FOR HOME AND COMMUNITY-BASED SERVICES

Background: Home and community-based services (HCBS) are long-term care services and supports that meet the needs of people who prefer to receive such services in their home or community, rather than in an institutional setting. In Medicaid, HCBS are optional services that many states offer through HCBS section 1915(c) waivers or the Medicaid state plan. HCBS include, but are not limited to, day services, supported employment and home-delivered meals.

Provision: The ARP increases the FMAP by 10 percentage points for state HCBS expenditures for four fiscal quarters (from April 1, 2021, through March 30, 2022). This funding is a supplement to current HCBS funding. States will not be permitted to use the funding for services not related to HCBS. The 10 percentage point FMAP bump for HCBS is an increase from the 7.35 percentage point FMAP bump included in the original version of the bill passed in the US House of Representatives.

DISPROPORTIONATE SHARE HOSPITAL ALLOTMENT TECHNICAL FIX

Background: Section 6008 of the Families First Coronavirus Response Act gave states a temporary 6.2 percentage point increase to each qualifying Medicaid program’s FMAP from January 1, 2020, through the last calendar quarter of the PHE.

Provision: The ARP makes a technical fix to state DSH allotment calculations to address an unintended consequence related to this temporary FMAP increase. Specifically, the ARP allows the Secretary of Health and Human Services to recalculate DSH allotments when the state received the 6.2 percentage point increase in FMAP. This change ensures that the total DSH payments that a state makes are equal to the total DSH payments that the state could have made for the fiscal year without the 6.2 percentage point increase in FMAP.

COVERAGE

COBRA PREMIUM ASSISTANCE

Background: Under long-standing federal law, individuals who lose their job or experience another qualifying event that results in termination of their employment-based health insurance are eligible to continue health insurance coverage through the Consolidated Omnibus Budget Reconciliation Act (COBRA). COBRA is often cost-prohibitive for affected individuals, however, as they may be required to pay up to 102% of the total premium.

Provision: The ARP makes COBRA coverage more affordable by subsidizing, on the individual’s behalf, 100% of the COBRA premiums during the period beginning the first month after ARP enactment until September 30, 2021.

MARKETPLACE ADVANCED PREMIUM TAX CREDIT

Background: The ACA established tax subsidies for health insurance purchased through insurance exchange marketplaces, known as advanced premium tax credits (APTCs). APTCs are available to individuals earning between 100% and 400% of the FPL.

Provision: For two years (2021 and 2022), the ARP expands availability of marketplace APTCs to eligible individuals whose income is above 400% of the FPL, based on a sliding scale. On one end of the sliding scale, individuals whose income is between 100% and 150% of the FPL are eligible for full coverage of their premiums. On the other end of the scale, individuals with incomes above 400% of the FPL will have their premiums capped at 8.5% of their income.

MEDICARE

FLOOR ON AREA WAGE INDEX FOR HOSPITALS IN ALL-URBAN STATES

Background: Generally, Medicare payments to providers are adjusted using a wage index to account for geographic variation in labor costs. The Centers for Medicare and Medicaid Services (CMS) calculates one wage index for each urban area and one for each rural area within each state. The Medicare statute provides that the wage index used to adjust hospital inpatient and outpatient payments for hospitals in an urban area cannot be less than the wage index applicable to hospitals in rural areas within that same state. This rule leaves a gap for three states that have no rural areas: New Jersey, Delaware and Rhode Island. Congress has periodically provided a patch for these three states, and CMS on its own volition perpetuated this patch through fiscal year 2018.

Provision: Effective October 1, 2021, the ARP restores the wage index “rural floor” protection for the all urban states of New Jersey, Delaware, Rhode Island and any other state that might be so designated in the future. Wage index changes are often controversial because historically they have been implemented in a budget-neutral fashion, which means the benefit given to some hospitals comes at the expense of others. The ARP spends new money to implement this change, so the benefit to hospitals in all-urban states will not come at the expense of others.

TEMPORARY WAIVER OF CERTAIN REQUIREMENTS FOR AMBULANCE SERVICES

Background: Medicare will only cover ambulance services to the nearest appropriate medical facility that is available. This requirement has posed an issue for ambulance providers and Medicare beneficiaries during the COVID-19 pandemic, because many hospitals have been at capacity and therefore an individual may not be transferred to the closest facility.

Provision: The ARP allows CMS to waive restrictions on payment for ambulance services where the individual was not transported to the closest appropriate facility during PHE declarations.

WHERE CONGRESS COULD GO NEXT

Congressional Democrats were limited in what they could include in the ARP because they relied on reconciliation to advance the bill without Republican support. Ordinarily, senators can block legislation through a filibuster, and it requires 60 votes to end a filibuster. Knowing that some Republicans might have thwarted progress on the bill using the filibuster, Democrats triggered the budget reconciliation process, which is immune from the filibuster and allowed Democrats to advance the bill relying on their 51-vote majority. However, reconciliation rules limit what can be advanced through this process, forcing Democrats to discard many priorities. Items included in the House version of the bill, or generally desired by Democrats but left out of the final bill, could re-appear in future legislation. Additionally, provisions sought by stakeholders but not embraced here, are likely to still be pushed.

MINIMUM WAGE AND 14(C) CERTIFICATES

Many Democrats have pushed for legislation to increase the federal minimum wage from the current $7.25 per hour to $15 per hour. Some states, localities and businesses have instituted a $15 minimum wage.

Section 14(c) of the Fair Labor Standards Act authorizes employers that obtain a certificate from the US Department of Labor Wage and Hour Division to pay special minimum wages (i.e., wages less than the federal minimum wage) to workers who have disabilities. Some states have phased out the 14(c) program, and there have been calls to phase out the program at the federal level.

The House version of the bill included a provision to phase in increases to the federal minimum wage to $15 per hour by 2025. The House bill would have discontinued the issuance of new 14(c) certificates, while allowing existing 14(c) certificate holders to continue using their subminimum wage certificates for five years after enactment. It also would have set the hourly wage paid to 14(c) covered employees to at least $5 in 2021 (or, if greater, the wage that was paid to the employee before the ARP’s enactment). Each subsequent year, the 14(c) subminimum wage would have increased by $2.50. In 2025, the subminimum wage paid to 14(c) covered employees would have been $15 per hour, and remaining 14(c) certificates would have had no legal effect.

The Senate substitute version of the bill removed these changes to the federal minimum wage and the 14(c) program following the Senate parliamentarian’s ruling that they did not meet Senate reconciliation rules. As a result, changes to the federal minimum are not included in the final version of the ARP.

MEDICAID COVERAGE OF JUSTICE-INVOLVED INDIVIDUALS DURING 30-DAY PERIOD PRECEDING RELEASE

State Medicaid programs are prohibited from financing the care of anyone committed to a jail, prison, detention center or other penal facility (otherwise known as a “justice-involved individual”) unless an inmate is treated in a medical institution outside the prison or jail for 24 hours or longer. States have been seeking avenues to cover transition services and care coordination for individuals exiting the justice system. At least six states (California, Illinois, Kentucky, New York, South Carolina and Utah) have explored using Section 1115 waivers (including COVID-19 1115 waivers) to expand Medicaid coverage to justice-involved individuals. To date, no 1115 waivers have been approved to expand Medicaid coverage to justice-involved individuals.

The House version of the ARP initially included a provision to permit Medicaid payments for services to justice-involved individuals enrolled in Medicaid during the last 30 days of their incarceration. This provision was removed from the bill prior to passage in the House, however. Ultimately, this provision was not included in the final bill.

MEDICARE ACCELERATED AND ADVANCED PAYMENTS TO PROVIDERS

On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program, which allows pre-payment of Medicare claims in emergencies, to a broader group of Medicare providers. On April 26, 2020, CMS announced suspension of these payments.

The Continuing Appropriations Act, 2021 and Other Extensions Act, enacted on October 1, 2020, changed the repayment schedule, allowing providers up to one year from receiving the accelerated or advance payment to reimburse CMS. After that point, Medicare payments owed by providers and suppliers will be recouped at a rate of 25% for 11 months. After that time period, the payments will be recouped at a rate of 50% for another six months. After the final six months, the remaining balance will be due, and interest will attach at a rate of 4%.

Although many providers have pushed for more favorable terms for loan repayment and forgiveness, the ARP does not address accelerated and advance payments. Expect an additional uptick in concern about these programs in April 2021 when recoupment begins for some providers.

TELEHEALTH

HHS and Congress provided waivers and flexibilities related to telehealth services during the PHE. These have allowed a significant expansion of telehealth use, increasing access for patients and giving providers additional means to ensure continuity of care while the pandemic limits in-person visits. These flexibilities have also allowed providers to use new, innovative ways to treat patients with mental and behavioral health issues, as well as chronic conditions such as diabetes and hypertension.

Stakeholders have emphasized the importance of maintaining these flexibilities beyond the pandemic. The waivers are tied to the authority provided through the PHE, however. In order to stay effective, the PHE must be renewed by HHS every 90 days. While the current PHE declaration runs through April 20, 2021, the Biden Administration has indicated that it likely will extend the PHE through the end of 2021. Stakeholders are hopeful that Congress will make permanent some of the telehealth waivers before the end of the year.

MEDICARE SEQUESTER RELIEF

The Budget Control Act of 2011, as amended, established that Medicare payments are subject to reductions of up to 2% across the board from 2013 through 2029. The CARES Act suspended Medicare sequestration payment reductions from May 1, 2020, through December 31, 2020. To make up for the budget savings lost during this temporary suspension, the application of the 2% sequestration was extended through 2030.

The Consolidated Appropriations Act, 2021, extended the Medicare suspension through the first quarter of 2021. Absent congressional action, the 2% sequester is scheduled to go into effect on April 1, 2021.

The passage of the ARP will likely trigger a statutory provision created in the Statutory Pay-As-You-Go Act of 2010. The law requires that automatic payment cuts be put into place if a statutory action creates a net increase in the deficit. The Congressional Budget Office has estimated that it would require reductions in Medicare spending of four percentage points (or an estimated $36 billion) for fiscal year 2022 if congressional action is not taken to waive the requirement.

Providers participating in the Medicare program should be aware that payment cuts could be implemented absent congressional action, and that advocacy to waive the payment cuts is likely to begin immediately. 

PAYMENT FOR PHYSICIAN SERVICES

The Consolidated Appropriations Act, 2021, directed Medicare to make a 3.75% positive adjustment to calendar year 2021 physician payments, which was applied to the Medicare physician conversion factor. This provision helped mitigate (but did not eliminate) scheduled payment cuts to Medicare physician services for calendar year 2021. The Medicare physician fee schedule is a budget-neutral payment system, and these payment cuts were largely driven by increased spending for office/outpatient evaluation and management services, typically delivered by primary care providers and certain specialty physicians.

The 3.75% payment boost was authorized for only one year, which means that physicians will again face reductions in 2022 unless Congress acts. The ARP does not include a fix for this impending payment cut, but stakeholders are urging Congress to act before the end of 2021.

CONCLUSION

The ARP will be touted as a major accomplishment in the new administration’s first 100 days. It makes clear that a Democrat-led Washington will be focused heavily on coverage expansion, particularly through incentives to expand Medicaid that look almost identical to those used when the ACA was first passed during the Obama Administration.

While the ARP is robust in federal action, it also maintains a high degree of flexibility for state and local governments to respond to COVID-19-related needs, both for general economic recovery and healthcare support.

Democrats are highly likely to use reconciliation again in 2021, and Congress will be considering must-pass legislation relating to the debt limit and fiscal funding later this year. There will be many opportunities for the provisions that were not included in the ARP to be considered this year. However, Democrats are likely to face mounting scrutiny on high spending, particularly as the Medicare Hospital Insurance Trust Fund hurtles toward insolvency, the debt limit demands attention and Medicare sequestration looms on the horizon.

The post American Rescue Plan Act Of 2021: Key Healthcare Provisions appeared first on mTelehealth.

American Rescue Plan Act of 2021: Summary
The U.S. House of Representatives on March 10, 2021, passed the Senate-amended H.R. 1319, the
American Rescue Plan (ARP). The ARP provides $1.9 trillion in additional relief to respond to the novel
coronavirus (COVID-19). This follows the enactment of nearly $4 trillion in COVID relief in 2020. President
Joe Biden called for Congress to enact the ARP to provide relief for individuals and business struggling due
to COVID-19, as well as to achieve other priorities of the Biden Administration and Congress. ARP includes
provisions on aid to state and local governments, hard-hit industries and communities, tax changes affecting
individuals and business, and other provisions.
The latest COVID relief legislation was enacted as part of Congress’ fiscal year (FY) 2021 budget, and
includes provisions impacting a wide variety of stakeholders. The following chart highlights some noteworthy
provisions.
Key Provisions of American Rescue Plan
Agriculture
Food supply chain and agriculture pandemic response
 Provides $4 billion for the U.S. Department of Agriculture (USDA)
Secretary to:
o Purchase food and agricultural commodities
o Purchase and distribute agricultural commodities (including fresh
produce, dairy, seafood, eggs and meat) to individuals in need
o Make grants and loans for small or midsized food processors or
distributors, producers or other organizations to respond to COVID
o Make loans and grants to maintain and improve food and
agricultural supply chain resiliency
 Provides $300 million to monitor and survey susceptible animals for
incidents of COVID
 Provides $100 million to reduce the amount of overtime inspection costs of
federally inspected small establishments and very small establishments
engaged in meat processing
Emergency rural development grants for rural healthcare
 Provides $500 million to establish an emergency pilot program within 150
days after the enactment of ARP to increase capacity for vaccine
distribution, purchase medical supplies, reimburse lost revenue, increase
telehealth capabilities, construct temporary or permanent structures to
provide healthcare services, support staffing needs for vaccine
administration and testing, and engage in other efforts to support rural
healthcare facilities in addressing COVID
Pandemic program administration funds
 Provides $47.5 million for necessary expenditures associated with carrying
out the agriculture subtitle
Funding for the USDA Office of Inspector General for oversight of COVID-related
programs
 Provides $2.5 million for audits, investigations and other oversight
activities carried out with funds made available to the USDA related to the
COVID pandemic
Farm loan assistance for socially disadvantaged farmers and ranchers
 Provides that the USDA Secretary shall provide a payment up to 120
percent of the outstanding indebtedness of each socially disadvantaged
farmer or rancher as of Jan. 1, 2021, to pay off the loan directly or to the socially disadvantaged farmer or rancher for a direct farm loan or farm
loan guaranteed by the Secretary
USDA assistance and support for socially disadvantaged farmers, ranchers, forest
land owners and operators, and groups
 Provides $1.01 billion to provide assistance for socially disadvantaged
farmers, ranches, forest land owners, operators and groups, including:
o not less than 5 percent to provide outreach, mediation, financial
training, capacity building training, cooperative development
training and support, and other technical assistance
o not less than 5 percent to provide grants and loans to improve
land access for socially disadvantaged farmers, ranchers or forest
landowners
o not less than 0.5 percent to support the activities of equity
commissions
o not less than 5 percent to support research, education and
extension, including scholarships and internships that provide
pathways to federal employment
o not less than 5 percent to provide assistance to socially
disadvantaged farmers, ranchers, or forest landowners who have
suffered adverse actions, past discrimination or bias
Use of the Commodity Credit Corporation (CCC) for commodities and associated
expenses
 Provides $800 million for the CCC to acquire and make available
commodities under Section 406(b) of the Food for Peace Act
Nutrition Assistance
Supplemental nutrition assistance program (SNAP)
 Extends the 15 percent increase in SNAP benefits through Sept. 30, 2021,
to address the hunger crisis.
 Provides $1.15 billion for SNAP. Of these funds:
o $15 million for the management and oversight of the program
o $1.135 billion to make grants to each state agency for fiscal years
2021-2023:
 75 percent of funds will be distributed based on the share
of each state’s households that participated in the
program for the most recent 12-month period
 25 percent of funds will be distributed based on the
increased number of households that participated in the
program for the most recent 12-month period
Additional assistance for SNAP online purchasing and technology improvements
 Provides $25 million to make technological improvements to improve
online purchasing, modernize electronic benefit transfer technology,
support mobile technologies demonstration projects and provide technical
assistance to educate retailers on the online acceptance of SNAP benefits
Additional funding for nutrition assistance programs
 Provides $1 billion in nutrition assistance for the Commonwealth of
Northern Mariana Islands, Puerto Rico and American Samoa
Commodity supplemental food program
 Provides $37 million for the commodity distribution program to maintain
the traditional levels of assistance for food assistance programs, including
but not limited to, distribution to institutions (including hospitals and
facilities caring for needy infants and children), supplemental feeding
programs serving women, infants and children (WIC) or elderly persons,
disaster areas, summer camps for children, the Trust Territory of the Pacific Islands and tribal organization requests for the distribution of
federally donated foods pursuant to Section 4(b) of the Food and Nutrition
Act of 2008
Improvements to WIC benefits
 Provides $490 million to increase cash vouchers for any state agency that
notifies the Secretary of the Department of Agriculture of the intent to use
the increased amounts. The authority of a state agency to increase the
amount of a cash-value voucher will terminate on Sept. 30, 2021
WIC program modernization
 Provides $390 million to carry out outreach, innovation and program
modernization efforts, including appropriate waivers and flexibility, to
increase participate in and redemption of benefits under programs
established under Section 17 of the Child Nutrition Act of 1966
Meals and supplements reimbursements for individuals who have not attained the
age of 25
 Permits the Secretary of the Department of Agriculture to reimburse
emergency shelter institutions for meals and supplements serving
individuals who are under the age of 25 and are receiving assistance,
including non-residential assistance, from the emergency shelter
Pandemic Electronic Benefit Transfer (P-EBT) program
 Amends Section 1101 of the Families First Coronavirus Response Act to
permit a state agency to extend a state agency plan for 90 days for the
purpose of operating a program during a covered summer period when the
school lunch program under the Richard B. Russell National School Lunch
Act or the school breakfast program under Section 4 of the Child Nutrition
Act of 1966 (42 U.S.C. 1773) and covered child care facilities are closed
Education
K-12 Education
 Nearly $122 billion for the K-12 General Stabilization Fund
 $2.6 billion for State Special Education Grants under the Individuals with
Disabilities Education Act (IDEA), to be used in FY 2021.
 $800 million to help children experiencing homelessness
 Stipulations for use:
o States are required to sub-grant at least 90 percent of the
Elementary and Secondary School Emergency Relief Fund
(ESSERF) to school districts according to Title I of the Every
Student Succeeds Act (ESSA) – this includes charter schools that
are considered Local Educational Agencies (LEAs)
o Of these funds, State Educational Agencies (SEAs) need to
reserve at least 5 percent and LEAs must reserve at least 20
percent to “address learning loss through the implementation of
evidence-based interventions, such as summer learning or
summer enrichment, extended day, comprehensive afterschool
programs, or extended school year programs, and ensure that
such interventions respond to students’ academic, social, and
emotional needs”
o States need to disseminate the funding within 60 days of receipt;
within 30 days of getting the new relief funding, school districts
have to publish “a plan for the safe return to in-person instruction”
if they have not already done soHigher Education
 $40 billion to colleges and universities through the Higher Education
Emergency Relief Fund (HEERF), which will remain available through
Sept. 30, 2023, including:
o $36 billion for public and nonprofit institutions of higher education
 institutions are required to direct 50 percent of their
funding to students in the form of emergency grants
o $3 billion for Historically Black Colleges and Universities (HBCUs),
Tribal Colleges and Universities (TCUs) and other Minority Serving
Institutions (MSIs)
o $198 million for institutions with the greatest pandemic-related
needs
Child Care
Child Care
 $40 billion for child care agencies and aid to providers affected by the
pandemic:
o $15 billion of these funds will go to the Child Care and
Development Block Grant (CCDBG) to subsidize child care for
875,000 children during the next year
o $24 billion is for child care stabilization funds to save and sustain
nearly 449,000 child care programs, impacting 7.3 million children
o $1 billion for Head Start to ensure that programs can continue to
provide vital services to children and families
Water and Utility
Assistance
Funding for LIHEAP
 Provides $4.5 billion for utility assistance through the Low Income Home
Energy Assistance Program (LIHEAP)
Funding for water assistance program
 $500 million for water assistance grants to states “to assist low-income
households, particularly those with the lowest incomes, that pay a high
proportion of household income for drinking water and wastewater
services”; the states will provide the funds to” owners or operators of
public water systems or treatment works to reduce arrearages of and rates
charged to such households for such services”
Healthcare
Public Health
Funding for COVID-19 vaccine activities at the Centers for Disease Control and
Prevention (CDC)
 Provides $7.5 billion to the CDC for activities to plan, distribute and track
COVID-19 vaccines; these funds may also go to state, local, tribal and
territorial public health departments for wraparound support for vaccine
distribution and administration, and will be available until expended and
will be distributed through existing CDC vehicles/cooperative agreements
to the public health departments/officials in the 64 CDC jurisdictions
 This section also provides additional supplemental funding to states,
localities and territories within 21 days of enactment above and beyond
similar funding provided in the FY 2021 regular appropriations bill based
upon the difference between FY 2021 funding and the FY 2020 Public
Health Emergency Preparedness grant formula funding
Funding for Vaccine Confidence Activities
 Provides $1 billion to the CDC to strengthen public understanding and
confidence in COVID-19 vaccines to ultimately improve U.S. vaccination
rates; the funds will be available until expended and will be distributed
through existing CDC vehicles/cooperative agreements to the public health
departments/officials in the 64 CDC jurisdictions Funding for Supply Chain for COVID-19 Vaccines, Therapeutics and Medical
Supplies
 Provides $6.05 billion for research, development, manufacturing,
production and purchase of vaccines, therapeutics and ancillary medical
products and supplies to respond to COVID; funding may apply not only to
COVID-19 but also to any pandemic-capable disease, and will be available
until expended and will likely be available through U.S. Department of
Health and Human Services (HHS) contract vehicles/Broad Agency
Announcements
Funding for COVID-19 Vaccine, Therapeutic and Device Activities at the FDA
 Provides $500 million to the U.S. Food and Drug Administration (FDA) to
evaluate the continued effectiveness of FDA-regulated products approved
to address COVID-19; funding also applies to expand continuous
manufacturing abilities to ensure a robust supply chain of COVID-related
products, and also may also be used to expand FDA facility inspections to
accelerate the review of products delayed due to COVID
Reduced Cost-Sharing
 Ensures that individuals who received unemployment compensation in
2021 receive cost-sharing subsidies as those whose family income is no
greater than 133 percent of the federal poverty line
Testing
Funding for COVID-19 Testing, Contact Tracing and Mitigation Activities
 Provides HHS with $47.8 billion to fund activities to respond to and
mitigate the spread of COVID-19, and that may be used to:
o implement a national COVID-19 testing strategy
o provide technical assistance to state, local and territorial public
health departments to detect, diagnose and trace COVID-19
o support expanded COVID-19 testing and development, including
through the acquisition of non-federally owned facilities to increase
testing capacity
o enhance IT resources for public health data sharing.
 The funds will be available until expended and will be distributed through
existing CDC vehicles/cooperative agreements, including and especially
the Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement
to the public health departments/officials in the 64 CDC jurisdictions
Funding for SARS-COV-2 Genomic Sequencing and Surveillance
 Provides HHS/CDC with $1.75 billion to expand and improve activities
around the sequencing of COVID-19 and its variants; funding may also
apply to local, state and territorial health departments to develop COVID
variant mitigation strategies
Funding for Global Health
 Provides $750 million to HHS/CDC to combat COVID-19 and emerging
infectious diseases globally
Funding for Data Modernization and Forecasting Center
 Provides $500 million to HHS/CDC for public health data surveillance and
analytics infrastructure modernizationPublic Health Workforce
Funding for Public Health Workforce
 Provides $7.66 billion to HHS to maintain and expand the U.S. public
health workforce, including through grant support to public health
departments to recruit and hire new public health workers and related
administrative support as well as providing PPE and other supplies to new
workers
Funding for Medical Reserve Corps
 Provides $100 million for the Medical Reserve Corps
Public Health Investments
Funding for community health centers and community care
 Provides $7.6 billion to HHS to be awarded for grants and cooperative
agreements to community health centers and qualified Hawaiian entities
for COVID-19 vaccine distribution, testing, contract tracing, equipment,
staff, infrastructure, and community education and outreach
Funding for National Health Service Corps
 Provides $800 million to HHS for state loan repayment programs
Funding for Nurse Corps
 Provides $200 million to HHS for loan repayment programs
Funding for teaching health centers that operate graduate medical education
 Provides $330 million through FY 2023 to HHS for new graduate medical
residency training programs, maintaining existing staff and expanding
existing programs, establishing new or expanding existing primary care
residency programs, funding a per resident increase of $10,000 and
boosting the federal response to public health emergencies
Funding for family planning
 Provides $50 million to HHS for federal grants to assist in the
establishment and operation of family planning and preventive health
projects and services not including abortion services
Mental Health and Substance Use Disorder
Funding for block grants for community mental health services
 Provides $1.5 billion to HHS through FY 2025 for grants to states for
providing community mental health services
Funding for block grants for prevention and treatment of substance abuse
 Provides $1.5 billion to HHS through FY 2025 for substance abuse
prevention and treatment
Funding for mental health and substance use disorder training for healthcare
professionals, paraprofessionals, and public safety officers
 Provides $80 million to HHS and the Health Resources and Services
Administration (HRSA) for grants or contracts with qualifying entities in
rural and underserved communities to train health professionals in
evidence-informed strategies for reducing and addressing suicide,
burnout, mental health conditions and substance use disorders among
healthcare professionalsFunding for education and awareness campaign encouraging healthy work
conditions and use of mental health and substance use disorder services by
healthcare professionals
 Provides $20 million to HHS/CDC to carry out a national evidence-based
education and awareness campaign directed at healthcare professionals
and first responders by encouraging them to identify risk factors and seek
support and treatment for their own mental health and substance use
concerns
Funding for grants for healthcare providers to promote mental health among their
health professional workforce
 Provides $40 million to HHS/HRSA for grants or contracts with healthcare
entities, including provider trade associations and Federally Qualified
Health Centers (FQHCs), to establish or expand protocols to promote
mental health among healthcare providers, particularly in rural and
underserved communities
Funding for community-based funding for local substance use disorder services
 Provides $30 million to HHS to support community-based overdose
prevention programs, syringe services programs and other harm reduction
services
Funding for community-based funding for local behavioral health needs
 Provides $50 million to HHS for grants to address increased community
behavioral health needs worsened by the COVID-19 public health
emergency to be used for care coordination, workforce training, surge
capacity, integrating evidence-based care models, providing mental and
behavioral health services via telehealth, and preventive and crisis
intervention services
Funding for the National Child Traumatic Stress Network
 Provides $10 million to HHS in funding for the national child traumatic
stress network
Funding for Project AWARE
 Provides $30 million to HHS for Project AWARE for advancing wellness
and resiliency in education
Funding for youth suicide prevention
 Provides $20 million to HHS for grants for youth suicide and early
prevention programs
Funding for behavioral health workforce education and training
 Provides $100 million to HHS for grants for mental and behavioral health
education and training programs
Funding for pediatric mental health care access
 Provides $80 million to HHS for grants to promote behavioral health
integration in pediatric primary care by supporting the development of new
or improvement of existing statewide or regional pediatric mental health
care telehealth access programs
Funding for expansion grants for certified community behavioral health clinics
 Provides $420 million to HHS for grants to Certified Community Behavioral
Health ClinicsExchange Grant Program
Establishing a grant program for ACA Exchange modernization
 Provides $20 million through FY 2022 to HHS to award grants to
Affordable Care Act (ACA) Exchanges to modernize or update systems,
programs or other technology
Medicaid
Mandatory coverage of COVID–19 vaccines and administration and treatment
under Medicaid
 The bill builds on provisions in the Families First Coronavirus Response
legislation that required Medicaid and Children’s Health Insurance
Program (CHIP) coverage of COVID-19 testing without cost-sharing to
explicitly require Medicaid and CHIP coverage of COVID-19 vaccines,
treatment including prescription drugs and treatment of conditions that
complicate COVID-19 treatment, without the imposition of cost-sharing
charges
Modifications to certain coverage under Medicaid for pregnant and postpartum
women
 Full benefits would be available to women during pregnancy and
throughout the 12-month postpartum period, or up to a year after the last
day of her pregnancy, extending their coverage well beyond the current
cutoff of 60 days; if a state selects this option for its Medicaid program, it
must provide it under its CHIP program
State option to provide qualifying community-based mobile crisis intervention
services
 The bill allows states to offer community-based mobile crisis intervention
services for five years, with an 85 percent Federal Medical Assistance
Percentage (FMAP)
Temporary increase in FMAP for medical assistance under state Medicaid plans
that begin to expend amounts for certain mandatory individuals
 States that newly expand Medicaid would receive an additional 5
percentage point increase in their regular FMAP for two years, no matter
when they newly expand – this increase would be in addition to the
temporary 6.2 percentage point FMAP increases enacted as part of the
Families First Coronavirus legislation available through the duration of the
COVID-19 public health emergency; the 5-percentage point increase
would not apply to other Medicaid spending that is not subject to the
regular FMAP, such as administrative costs and Disproportionate Share
Hospital (DSH) spending
Extension of 100 percent federal medical assistance percentage to Urban Indian
Health Organizations and Native Hawaiian Health Care Systems
 For two years, the bill would temporarily apply the 100 percent FMAP
available to Indian Health Service (IHS) providers furnishing care to
Medicaid beneficiaries to include Urban Indian Health Programs and
Native Hawaiian Health Care Systems services; such providers are
grantees of the IHS and serve IHS-eligible patients on Medicaid, but they
are not formally part of the IHS and, as a result, do not receive the 100
percent FMAP like other IHS providersSunset of limit on maximum rebate amount for single-source drugs and innovator
multiple source drugs
 The bill delayed by one year, until 2024, the removal of the cap on
Medicaid inflation rebates; Medicaid requires a minimum 23 percent rebate
on brand drugs, and companies pay an additional inflation rebate when
they raise prices faster than inflation – that inflationary rebate is currently
capped at 100 percent of the Average Manufacturer Price (AMP) to avoid
making drug companies pay rebates that are greater than the price of
drugs
Additional support for Medicaid home and community-based services during the
COVID–19 emergency
 States would have the option of receiving a 7.35 percentage point increase
in their Medicaid matching rate for home and community-based services
(subject to a 95 percent limit) for one year starting April 1, 2021; as a
condition of the increase, states would be required to use this additional
funding to expand and enhance home and community-based services in
one or more enumerated ways, including increasing home and communitybased reimbursement rates and providing payments to financially stressed
providers
Funding for state strike teams for resident and employee safety in nursing facilities
 The bill appropriates $250 million to support state-based “strike” teams to
help respond to COVID-19 in nursing homes
Medicare
Floor on the Medicare area wage index for hospitals in all-urban states
 The bill restores an area wage index floor for hospitals in all-urban states
starting Oct. 1, 2021, and directs the HHS Secretary to create a Medicare
area wage index for hospitals in all-urban states to address a 2019 rule
that imposed across-the-board cuts to increase pay for low-wage hospitals
Secretarial authority to temporarily waive or modify application of certain Medicare
requirements with respect to ambulance services furnished during certain
emergency periods
 The bill provides for Medicare reimbursement to ambulance providers
even if the patients aren’t transported to a healthcare facility; the authority
would last the duration of the public health emergency
Funding for Office of Inspector General
 The bill provides $5 million to the HHS Office of Inspector General (OIG)
for oversight activities with respect to the Provider Relief Fund
Defense Production
Act
 Provides $10 billion to carry out the Defense Production Act for medical
supplies and equipment such as testing, personal protective equipment
(PPE) and vaccines.
Housing,
Homelessness and
Rental Assistance
Emergency rental assistance
 Of the $27.4 billion provided for rental assistance, $21.55 billion will be
funded through the Coronavirus Relief Fund (CRF) and administered by
the U.S. Department of the Treasury:
o $305 million is set aside for territories
o $152 million is set aside for states
o $2.5 billion will be distributed to high-need communities and will be
distributed based on the number of very low-income renter
households paying more than 50 percent of income on rent or living in substandard or overcrowded conditions, rental market
costs and employment trends.
o See State Estimates for Emergency Rental Assistance
 Allocations: The first 40 percent of funds must be paid to grantees within
60 days of enactment; when a grantee has obligated not less than 75
percent of funds already dispersed, the Treasury Secretary may provide
additional disbursements of the grantee’s allocation
 Eligibility: Under the bill, households are eligible for emergency rental
assistance funds if one or more individuals: 1) has qualified for
unemployment benefits or experienced a reduction in household income,
incurred significant costs, or experienced other financial hardship during or
due, directly or indirectly, to the pandemic; 2) can demonstrate a risk of
experiencing homelessness or housing instability; and 3) has a household
income below 80 percent of the Area Median Income (AMI)
o States and localities must prioritize households below 50 percent
of AMI or those who are unemployed and have been unemployed
for 90 days; states and localities can provide additional
prioritization of funds
 Use of Funds: The funds must be used to provide financial assistance,
including back and forward rent and utility payments, and other housing
expenses, and assistance can be provided for 18 months; not more than
10 percent of funds may be used to provide case management and other
services intended to help keep households stably housed, and not more
than 15 percent of funds paid to a state or local government can be used
for administrative costs
 Deadlines: After March 31, 2022, the Treasury Secretary may recapture
excess funds not obligated by a state or locality and reallocate and repay
these dollars to eligible grantees who, at the time of such reallocation,
have obligated at least 50 percent of the amount originally allocated and
have met other criteria; funds not obligated may be used to provide
affordable housing to very low-income households, so long as the grantee
has obligated at least 75 percent of its total allocation, and funds provided
under this bill are available until Sept. 30, 2025
o The bill extends the deadline to spend the initial $25 billion tranche
of funding provided by Congress in December 2020 from Dec. 31,
2021 to Sept. 30, 2022.
Emergency housing vouchers
 Provides $5 billion for housing vouchers with funds available through Sept.
30, 2030.
 Use of Funds: These funds must be used to provide and renew
emergency vouchers, to cover administrative costs and to make
adjustments for public housing agencies that would otherwise be required
to terminate rental assistance due to a significant increase in voucher perunit costs due to extraordinary circumstances
 Eligibility: Under the bill, households are eligible for emergency vouchers
if they 1) are or are at risk of experiencing homelessness, 2) are fleeing or
attempting to flee domestic violence, dating violence, stalking, sexual
assault or human trafficking, or 3) are recently homeless and rental
assistance will prevent the family’s homelessness or having a high risk of
housing instability
 Allocations: Public housing agencies will be notified of the number of
vouchers allocated to them within 60 days, with vouchers to be distributed
by a formula that includes capacity and ensures geographic diversity, and
the Secretary may revoke and redistribute any unleased vouchers after a
reasonable time; a public housing agency may not reissue any vouchers
after Sept. 30, 2023, when assistance for the family assisted ends Emergency assistance for rural housing
 Provides $100 million in rental assistance to assist rural households living
in USDA-financed properties; funds are available until Sept. 30, 2022, and
they may be used to cover back rent and ongoing rental assistance
Housing counseling
 $100 million for housing counseling through NeighborWorks America. Of
the funds provided, not less than 40 percent must be provided to housing
counseling organizations that 1) target minority and low-income
homeowners, renters and individuals experiencing homelessness or 2)
provide services in neighborhoods with high concentrations of minority and
low-income homeowners, renters and individuals experiencing
homelessness.
Homelessness assistance and supportive services program
 Provides $5 billion to provide rental assistance and supportive services, to
develop affordable rental housing, to help acquire non-congregate shelter
to be converted into permanent affordable housing or used as emergency
shelter
 Eligibility: These funds must primarily benefit 1) individuals or households
that are or are at risk of experiencing homelessness, 2) people who are
fleeing or attempting to flee domestic violence, dating violence, stalking,
sexual assault or human trafficking, 3) populations for whom supportive
services would prevent the family’s homelessness or having a high risk of
housing instability, or 4) households with a veteran family member that
meets one of these criteria
 Allocations: Funds will be allocated within 30 days of enactment using the
HOME Investment Partnerships program formula; the bill waives statutory
requirements, including a commitment deadline, matching requirements
and set-aside for Community Housing Development Organizations
(CHDOs).
o See National Low Income Housing Coalition Estimated Allocations
of Homeless Assistance Grants
 Administrative Costs: Up to 15 percent of the funds may be used to
cover administrative costs; a grantee may receive up to an additional 5
percent of its allocation for operating costs for certain CHDOs and
nonprofit organizations if the funds are used to build capacity
Homeowner Assistance Fund
 Provides $9.961 billion in funding to be distributed to states through the
U.S. Department of the Treasury
 States can apply for the fund 45 days after enactment – reducing the
likelihood that there will be implementing regulations; instead, Treasury will
dictate terms through the contracts with the states
 Impacts existing pipeline of delinquencies – tolling date is Jan 21, 2020;
expenses related to delinquencies prior to January 2020 are not eligible,
but there is no requirement that the loan be performing as of January 2020
in order to avail themselves of support
 Eligible uses of the funds include: mortgage payments; principal reduction;
interest rate reductions; funds to reinstate a mortgage after forbearance,
delinquency or default; payment assistance for utilities, internet, property
taxes, homeowners insurance, mortgage insurance, flood insurance,
condo fees and homeowner association fees; and a catch-all for “any other
assistance to promote housing stability”
 Unlike the Hardest Hit Fund, the money is not directly earmarked to state
housing finance agencies (HFAs), but it is likely that states will rely on
state HFAs to do principal write-downs and interest rate reduction
refinance loans (IRRLs) States can also use the money to reimburse themselves for their own
programs that pre-date disbursement from the Treasury Department
 States have to spend 60 percent of the funds on borrowers at or below the
AMI
 The maximum amount of support is the government-sponsored enterprise
(GSE) conforming loan limit
Relief measures for Section 502 and 504 direct loan borrowers
 Provides $39 million to assist rural homeowners through USDA’s Section
502 and Section 504 direct loan programs
Fair Housing Initiatives Program
 $20 million increase to the U.S. Department of Housing and Urban
Development’s (HUD) Fair Housing Initiatives Program (FHIP) to help
identify government agencies that handle complaints of housing
discrimination
 Eligible grantees include state or local governments, qualified fair housing
enforcement organizations with at least two years of experience, and other
public or private nonprofit organizations representing individuals who have
been victims of housing discrimination
Public Transportation
Federal Transit Administration Grants
 $30.5 billion for transit
o $26.086 billion for Federal Transit Administration (FTA) Urbanized
Area Formula Grants (Section 5307)
 This amount, combined with CARES Act and Coronavirus
Response and Relief Supplemental Appropriations Act
(CRRSAA) grants, allows urbanized areas to receive 132
percent of their 2018 operating costs; for urbanized areas
that received grants totaling 130 to 132 percent of
operating costs from the CARES Act and CRRSAA, they
receive an additional 10 percent of their 2018 operating
costs
o $317 million for FTA Rural Area Formula Grants (Section 5311)
o $50 million for FTA Enhanced Mobility for Seniors and Individuals
with Disabilities Grants (Section 5310)
o $100 million for non-urbanized intercity bus program recipients
o $25 million for Section 5307 planning grants to restore service
 $2.21 billion for operating assistance grants to eligible recipients that
require additional support for operations, personnel, cleaning, sanitization
and debt payments costs incurred to maintain operations and avoid layoffs
and furloughs due to COVID-19, with grants to be evaluated by the FTA
based on the level of financial need demonstrated; the FTA is required to
issue a Notice of Funding Opportunity (NOFO) for these grants within 180
days after the bill is signed into law
 $1.675 billion for Capital Investment Grants (CIG)
o $1.425 billion for New Start and Core Capacity projects:
 $1.25 billion for CIG project sponsors that have an existing
Full Funding Grant Agreement (FFGA) and have received
a FY 2019 or FY 2020 CIG allocation.
 $175 million to CIG projects with an existing FFGA that
received a CIG allocation prior to FY 2019
o $250 million for Small Start projects that are a recipient of a CIG
allocation or an applicant in the project development phaseDisaster Relief
Emergency Federal Employee Leave Fund
 Provides $570 million to establish a fund, the Emergency Federal
Employee Leave Fund, to be administered by the Office of Personnel
Management (OPM) to remain available through Sept. 30, 2022; funds
may be used for reimbursement to an agency or for paid leave by any
employee who is unable to work due to quarantine or isolation related to
COVID-19, including caring for family members or dependents, and paid
leave may not exceed 600 hours for each full-time employee
Pandemic Response Accountability Committee funding availability
 Provides $40 million to support oversight of the coronavirus response via
the Pandemic Response Accountability Committee
Funding for the White House
 Provides $12.8 million for the White House to prevent, prepare for and
respond to the coronavirus
Federal Emergency Management Agency appropriation
 Provides $50 billion for the Federal Emergency Management Agency
(FEMA) for the purposes of the Disaster Relief Fund (DRF) for cost
associated with major disaster declarations
Emergency food and shelter program funding
 Provides $400 million for the emergency food and shelter program
Humanitarian relief
 Provides $110 million for the emergency food and shelter program for the
purposes of providing humanitarian relief to families and individuals
encountered by the U.S. Department of Homeland Security (DHS)
AFG and SAFER program funding
 Provides $100 million for Assistance to Firefighter Grants (AFG) and $200
million for Staffing for Adequate Fire and Emergency Response Grants
(SAFER)
Emergency management performance grant funding
 Provides $100 million for emergency management performance grant
funding
Cybersecurity and
Technology
Modernization
Cybersecurity and Infrastructure Security Agency.
 Provides $650 million for the DHS Cybersecurity and Infrastructure
Security Agency (CISA) to mitigate cybersecurity risks
Appropriation for the U.S. Digital Service
 Provides $200 million for the U.S. Digital Service, a White House unit that
provides IT support to federal agencies
Appropriation for the Technology Modernization Fund
 Provides $1 billion for the General Services Administration Technology
Modernization Fund, which was established to upgrade federal agency IT
systems
Paycheck Protection
Program (PPP)
 Appropriates an additional $7.25 billion to the U.S. Small Business
Administration (SBA) for the PPP program
 Expands PPP eligibility to include:o Additional tax-exempt nonprofits, such as 501(c)(5) labor and
agricultural organizations and community locations of larger
nonprofits, whose lobbying activities do not comprise more than 15
percent of its activities
o Internet publishing organizations assigned a North American
Industry Classification System (NAICS) Code of 519130 and
engaged in the collection and distribution of local or regional and
national news and information
 Adds COBRA premium assistance as an allowable payroll cost under the
PPP program
 Program expires March 31, 2021
Economic Injury
Disaster Loans (EIDL)
 Appropriates $15 billion to the SBA to provide EIDL $10,000 grants to
small businesses eligible under Section 331 of the Economic Aid to HardHit Small Businesses, Nonprofits, and Venues Act or Section 1110(e) of
the CARES Act
Restaurants
 Appropriates $28.6 billion for the SBA to administer a grant program to
restaurants through a new Restaurant Revitalization Fund
 The new grant program follows the enactment of a similar grant program
for shuttered live venues enacted in Section 324 of the Economic Aid to
Hard-Hit Small Businesses, Nonprofits, and Venues Act enacted in
December 2020
 Eligible restaurants must certify that the uncertainty of current economic
conditions makes necessary the grant request to support the ongoing
operations of the restaurant
 The bill prohibits eligibility of a restaurant that:
o is a state or local government operated business
o owns or operates more than 20 locations as of March 13, 2020
o has a pending application for or has received a grant under SBA
shuttered live venues grant program, or
o is a publicly traded company
 The maximum grant amount is:
o $10 million per eligible entity and any affiliated businesses, and
o $5 million per physical location of the eligible entity
Shuttered Venue
Operators
 This bill provides $1.25 billion in additional funds for the Shuttered Venue
Operators Grant Program enacted in Section 324 of the Economic Aid to
Hard-Hit Small Businesses, Nonprofits, and Venues Act enacted in
December 2020
 The bill also allows eligible applicants to access both the Shuttered Venue
Operators Grant (SVOG) and PPP to address SVOG’s delayed start
Aviation/Airlines
Air Transportation Payroll Support Program Extension
 Provides $14 billion to extend Payroll Support Program funding for eligible
air carriers and contractors, with the new round of funding extending
restrictions on involuntary furloughs and reductions in pay rates or benefits
through Sept. 30, 2021, or the date on which funds are expended; it also
extends the restrictions on stock buybacks, dividends and capital
distributions through Sept. 30, 2022, and restrictions on executive
compensation to April 1, 2023.
 The Secretary of the Treasury is required to issue streamlined procedures
within five days of enactment and make initial payments under the
program within 10 days of enactment
Relief for Airports
 $8 billion for airports
o $6.492 billion for primary airports and certain cargo airports to use
for “costs related to operations, personnel, cleaning, sanitization,
janitorial services, combating the spread of pathogens at the
airport, and debt service payments”; the federal share is 100
percent $800 million “to provide relief from rents and minimum annual guarantees
to airport concessions”
 $608 million to pay the federal share of 100 percent for Airport
Improvement Program (AIP) grants awarded in FY 2021 or FY 2020
Emergency TSA Employee Leave Fund
 The legislation also adds an $13 billion emergency paid leave fund for
TSA employees that is similar to a leave program for FAA employees
included in the bill; the fund expires in September 2022.
Broadband
Funding for E-Rate support for emergency educational connections and devices
 Nearly $7.2 billion to create an Emergency Connectivity Fund to reimburse
schools and libraries for internet access and connected devices for
students and teachers learning remotely due to the pandemic; requires the
FCC to issue rules within 60 days of enactment to provide funding to
eligible schools and libraries to enable them to provide eligible connected
devices, internet service and equipment necessary to support internet
service to students and teachers, regardless of technology, for internet use
in locations other than a school or library, among other things
 $10 billion for states, territories and tribal governments to carry out critical
capital projects directly enabling work, education and health monitoring,
including remote options, in response to the public health emergency with
respect to COVID-19; this funding is intended to be focused on broadband
investment
Unemployment
Provisions
Unemployment Insurance extension
 Extends enhanced unemployment insurance until Sept. 6. 2021, including
the extra $300 Federal Pandemic Unemployment Compensation
 Extends Pandemic Unemployment Assistance to the self-employed, gig
workers, freelancers and others who would otherwise not regularly qualify
for unemployment insurance
 Extends Pandemic Emergency Unemployment Compensation for those
who exhaust state benefits to 53 weeks, from 24 weeks
Unemployment Insurance tax relief
 Creates a $10,200 tax exclusion for unemployment compensation in tax
year 2020 for those with incomes under $150,000
Tax
Stimulus payments
 Provides an additional $1,400 per qualifying individual in direct stimulus
payments; in addition to the $600 in supplemental payments enacted in
the December 2020 relief bill, this would fulfill Democratic demands for
$2,000 in payments
Child Tax Credit
 Temporary, fully refundable enhancement of the value of the Child Tax
Credit to $3,000 for children older than 6 and to $3,600 for children
younger than 6 – an increase in the current credit of $2,000, of which only
$1,400 is refundable; envisions that the tax credit can be claimed on a
monthly basis, rather than annually
Earned Income Tax Credit
 Temporarily and significantly increases the value of the Earned Income
Tax Credit, along with loosening eligibility requirements on incomeDependent Care Assistance
 Child and Dependent Care Tax Credit: Temporary, fully refundable
enhancement of the Child and Dependent Care Credit from the current
limitation of $1,050 per child or dependent up to $4,000
Credits for Paid Sick and Family Leave
 Extends the availability of paid sick and paid family leave tax credits, as
established in the Families First Coronavirus Response Act through Sept.
30, 2021
 Also expands eligibility to state and local governments that provide this
benefit
Employee Retention Credit
 Increases the availability and value of credit to those employers who
“severely financially distressed” (i.e., those who experienced a severe
decline in gross receipts) by allowing such employers to take all wages
into account, not just those that are paid for employees not providing
services
 Expands credit availability to employers who qualify as a “recovery startup
business” (i.e., those employers who began a trade or business after Feb.
15, 2020, and whose gross receipts average less than $1 million)
 Expands availability of the credit from the current deadline of June 30,
2021, to those wages paid in 2021
Premium Tax Credit
 Expands the Affordable Care Act’s premium tax credits for health
insurance that is purchased through an exchange
Miscellaneous Provisions
Repeal of election to allocate on worldwide basis
 Revokes an election that came into effect in 2021 to allow multinational
companies to allocate their interest expenses on a worldwide basis
Extension of Excess Business Loss Limitation
 Extends the limitation on excess business losses of non-corporate
taxpayers for one year, through 2026
Pensions
Expansion of limitation on excessive employee remuneration
 Expands the denial of deductibility currently found in IRC Section 162(m)
to an additional five highest compensated individuals
Pension Benefit Guaranty Corporation (PBGC) fund
 Creates a fund for the PBGC to assist certain struggling multiemployer
plans to cover benefits due through plan years ending in 2051
State and Local
Assistance
Coronavirus State and Local Fiscal Recovery Funds
 Of the approximately $350 billion for fiscal relief, 57 percent is allocated to
states and 35 percent to local governments
 The distribution formula is as follows:
o States and District of Columbia: $195.3 billion
 $25.5 billion is equally divided with state minimum of $500
million $169 billion based on the state share of unemployed
workers over a three-month period from October to
December 2020
o Local Governments: $130.2 billion divided evenly between noncounty municipalities and counties
 Counties: $65.1 billion in direct federal aid to all counties
based on the county share of the U.S. population based
on the most recent data available from the Census Bureau
 Non-County Municipalities: $65.1 billion to cities and
other non-county municipalities:
 $45.57 billion in direct federal aid for
municipalities with populations of at least
50,000, using a modified Community
Development Block Grant formula
 $19.53 billion for municipalities with
populations of less than 50,000 based on each
jurisdiction’s percentage of the state’s population;
aid is distributed through the states, with the
ability for states to request an extension if they are
unable to distribute within 30 days
 See State and Local Allocation Estimates
o U.S. Territories: $4.5 billion
o $20 billion to federally recognized tribal governments
 Allowable Uses of Funds: Funds may be used to:

1. respond to the public health emergency with respect to COVID-19 or
   its negative economic impacts, including assistance to households,
   small businesses and nonprofits, or aid to impacted industries such as
   tourism, travel and hospitality
2. for the provision of government services to the extent of the reduction
   in revenue (i.e. online, property or income tax) due to the public health
   emergency
3. make necessary investments in water, sewer or broadband
   infrastructure, or
4. include premium pay for eligible workers performing essential work (as
   determined by each state or tribal government) during the pandemic
   o Other key provisions:
    states are not allowed to use the funds to either directly or
   indirectly offset a reduction in the net tax revenue that
   results from a change in law, regulation or administrative
   interpretation during the covered period that reduces any
   tax
    No funds shall be deposited into any pension fund
    State and local governments are allowed to transfer to a
   private nonprofit organization, a public benefit corporation
   involved in the transportation of passengers or cargo, or a
   special-purpose unit of state or local government
    Reporting Requirements, Certification and Recoupment: Requires
   state and local governments to fulfill reporting requirements, such as:
   o states are required to report how funds are used and how their tax
   revenue was modified during the time that funds were spent during
   the covered period (covered period begins on March 3, 2021, and
   ends on the last day of the fiscal year a state or local government
   has expended or returned all funds to the U.S. Treasury).
   o local governments would be required to provide “periodic reports”
   providing a detailed accounting of the use of funds
   o if a state, county or municipality does not comply with any
   provision of this bill, they will be required to repay the U.S.
   Treasury an equal amount to the funds used in violation Administration of Recovery Funds: Funds will administered as follows:
   o funds would be distributed by the U.S. Department of the Treasury
   o the deadline to spend funds would be Dec. 31, 2024
   o payments will be divided into two equal tranches – within 60 days
   after enactment, the U.S. Treasury is required to release the first
   tranche allocated to a city, county or state; the second tranche
   cannot be released earlier than 12 months after the first payment
   o in order to receive a payment either under the first or second
   tranche, local governments must provide the U.S. Treasury with a
   certification signed by an authorized officer; the U.S. Treasury is
   required to pay the first tranche to counties not later than 60 days
   after enactment and the second payment no earlier than 12
   months after the first payment
   o The bill would provide $117 million for oversight and to promote
   transparency and accountability of all federal coronavirus relief
   funds, with $77 million for the Government Accountability Office
   and $40 million for the Pandemic Response and Accountability
   Committee
   State Small Business Credit Initiative
    $10 billion for the fund, administered by the Treasury Department
    The money is allocated to states to support programs of their own design
   and can include: loan participation programs, venture capital programs,
   collateral support programs, loan guarantee programs and capital access
   programs
   Funding for providers relating to COVID-19
    The bill provides an additional $8.5 billion in relief funding for rural entities
   – far short of the $35 billion sought by stakeholders
   Tribal Provisions
   COVID State Fiscal Recovery Fund
    Provides $20 billion (of $219.8 billion allocated to the COVID State Fiscal
   Recovery Fund) for tribal governments to mitigate the fiscal effects
   stemming from the COVID pandemic
   o $1 billion will be allocated equally among all tribal governments
   o $19 billion will be allocated among all tribal governments in
   amounts determined by the Secretary
   o Payments will be made to each tribal government within 60 days
   of enactment
   o Tribal governments can use the funds by Dec. 31, 2024, to:
    respond to or mitigate the COVID public health emergency
   and its negative economic impacts, including assistance to
   households, small businesses and nonprofits or to
   impacted industries such as tourism, travel and hospitality
    respond to workers performing essential work during the
   COVID public health emergency by providing premium
   pay to eligible workers of tribal governments that are
   performing such essential work, or by providing grants to
   eligible employers that have eligible workers who perform
   essential work
    provide government services to the extent of the reduction
   in revenue due to the pandemic in the most recent full
   fiscal year
    make necessary investments in water, sewer or
   broadband infrastructure
   o A tribal government is defined as the governing body of any Indian
   or Alaska Native tribe, band, nation, pueblo, village, community,
   component band or component reservation individually identified in the annual list published pursuant to the Federally Recognized
   Indian Tribe List Act of 1994 (25 U.S.C. 5131)
   Indian Health Service
    Provides $6.094 for Indian health
    $5.484 billion is allocated to carry out the Transfer Act, the Indian SelfDetermination and Education Assistance Act, the Indian Health Care
   Improvement Act, and titles II and III of the Public Health Service Act.
   o $2 billion is for lost reimbursements in accordance with Section 207 of
   the Indian Health Care Improvement Act
   o $500 million is for Purchased/Referred Care
   o $140 million is for information, technology, telehealth infrastructure,
   and the Indian Health Service electronic health records system
   o $84 million is for maintaining operations of the Urban Indian health
   program
   o $600 million is for necessary expenses to plan, prepare for, promote,
   distribute, administer and track COVID vaccines
   o $1.5 billion is for necessary expenses to detect, diagnose, trace and
   monitor COVID infections; mitigate the spread of COVID; and
   purchase supplies necessary for these activities
   o $240 million is to establish, expand and sustain a public health
   workforce to prevent, prepare for and respond to COVID
   o $420 million is for necessary expenses related to mental and
   behavioral health prevention and treatment services
    $600 million is for lease, purchase, construction, alteration, renovation or
   equipping health facilities to respond to COVID
    $10 million is for expenses relating to potable water delivery
   Bureau of Indian Affairs
    Provides $900 million to the Bureau of Indian Affairs
   o $100 million for tribal housing improvement
   o $772.5 million for tribal government services, public safety and
   justice, social services, child welfare assistance and other related
   expenses
   o $7.5 million for federal administrative costs and oversight
   o $20 million to provide and deliver potable water
   Housing Assistance and Supportive Services Programs for Native Americans
    Provides $750 million to remain available until Sept. 30, 2025, for tribal
   housing, of which:
   o $450 million is allocated for the Native American Housing Block
   Grant program and $5 million for the Native Hawaiian Housing
   Block Grant program
    distributed according to the same funding formula used in
   FY 2021
    may be used to prevent, prepare for and respond to
   COVID, including maintaining normal operations and
   funding affordable housing activities
   o $280 million is allocated for Indian Community Development Block
   Grants
    may be used to address emergencies that constitute
   imminent threats to health and safety and are designed to
   prevent, prepare for and respond to COVID
   o $10 million is allocated for technical assistance
   o $5 million is allocated for administrative costsCOVID-19 Response Resources for the Preservation and Maintenance of Native
   American Languages
    Provides $20 million for grants to ensure the survival and continuing vitality
   of Native American languages during the COVID pandemic
   Bureau of Indian Education
    Provides $850 million to be allocated by the Director of the Bureau of
   Indian Education for programs and activities operated or funded by the
   Bureau of Indian Education, for Bureau-funded schools, and for tribal
   colleges and universities
   American Indian, Native Hawaiian and Alaska Native Education
    Provides $190 million to be allocated by the Secretary of the Department
   of Education, of which:
   o $20 million for tribal education agencies pursuant to Section
   612(c) of the Elementary and Secondary Education Act of 1965
   o $85 million in grants pursuant to Section 6205(a)(1) of the
   Elementary and Secondary Education Act of 1965
   o $85 million for grants pursuant to Section 6304(a)(1) of the
   Elementary and Secondary Education Act of 1965
   For a complete list of tribal provisions, please email Kayla Gebeck Carroll at
   kayla.gebeck@hklaw.com.
   This summary was compiled by members of Holland & Knight’s Public Policy & Regulation Group. If
   you have questions or need further information, please contact the authors.
   DISCLAIMER: Please note that the situation surrounding COVID-19 is evolving and that the subject
   matter discussed in these publications may change on a daily basis. Please contact the your
   responsible Holland & Knight lawyer for timely advice

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