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Washington, DC Update 4/13/23
Legislative Updates
House and Senate lawmakers will return for legislative business on Monday, April 17.
Farm Bill and SNAP
Rep. Dusty Johnson (R-SD) has introduced the America Works Act of 2023 (H.R.1581), which would impose stricter work requirements for Able Bodied Adults Without Dependents (ABAWDs). It would amend the Food and Nutrition Act of 2008 by: 
  • Expanding the age for work requirements from 18-49 to 18-65
  • Closing the “loophole” that allows states to request more work requirement waivers if the number of available jobs for SNAP enrollees is less than the number of unemployed enrollees
  • Requiring enrollees and states to renew their work requirement waivers annually.
Here is an overview of SNAP’s current work requirements: 
Current Eligibility: 
  • General requirements
  • For non-exempt recipients aged 16-59 – often families or those with children
  • Must register for work or job training. They must take any suitable job that is offered, and they may not voluntarily quit their job or reduce their hours without good reason. Some states may require assigned employment or training programs.
  • Able-bodied adults without dependents (ABAWDs) requirements: 
  • Adults who are eligible to work and do not have dependent children  
  • Must participate in job training or work at least 80 hours per month (20 hours per week) to receive SNAP for longer than three months within a three-year time limit

Current Time Limits:  
  • If an ABAWD misses their work or training requirement for three months, they will become ineligible and be cut off from benefits for the remainder of this three-year time limit
  • Time limits were suspended during the height of the pandemic but will be reinstated this May
  • States can request waivers that exempt enrollees from the time limit if they have an unemployment rate of at least 10% or there are more enrollees than there are available jobs.  
How could this affect CYSHCN and their families?? This bill could become the basis for the proposed work requirements in the Farm Bill (which is the primary funding mechanism for nutrition support programs).
Unwinding of the Public Health Emergency & Medicaid Continuous Coverage
The COVID-19 national emergency came to an end on April 10 after the President signed a congressional resolution (H.J.Res.7) to bring it to a close, despite his strong opposition to the measure. The national emergency, which was instituted in 2020, was originally slated to expire alongside the COVID-19 public health emergency (PHE) on May 11, 2023.

HHS: Reinstatement of HIPAA Enforcement on May 11, 2023
The Department of Health and Human Services (HHS) issued a notice (press release) that several COVID-19 PHE flexibilities related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act will end on May 11, 2023. The specific flexibilities include:
  • Allowing use and disclosure of protected health information by business associates for public health oversight;
  • Enforcement of COVID-19 community-based testing during the PHE;
  • Not enforcing noncompliance with online scheduling applications for a COVID-19 vaccine appointment; and
  • Enforcement of telehealth remote communications
  • HHS’ Office of Civil Rights will provide a 90-day transition period to exercise its enforcement of remote telehealth communications until August 9, 2023.

HHS, DOL and Treasury: FAQs on Coverage of COVID-19 Testing and Vaccines by Health Plans After the Public Health Emergency Ends
This set of frequently asked questions  (FAQs) were issued (jointly by HHS, the Department of Labor, and the Department of Treasury) to help group health plans and health insurance issuers in the private market understand their obligations under the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security Act (CARES Act) related to coverage for COVID-19 diagnostic testing and vaccines following the expiration of the public health emergency. 

CDC: How end of PHE affects CDC work
Although the PHE ends on May 11, 2023, the CDC remains dedicated to preventing severe illness and death from COVID-19, particularly for populations at higher risk. 

What Does the End of the PHE Mean for CDC?
  • Most CDC COVID-19 data activities are not directly affected by the PHE (e.g., case and death reporting, national genomic surveillance, sentinel surveillance, wastewater surveillance, traveler genomic surveillance).
  • Hospital data reporting will continue through April 30, 2024, but reporting may be reduced from the current daily reporting to a lesser frequency. Additional details are provided below.
  • CDC, along with jurisdictional partners, is assessing ongoing surveillance needs and potential revisions to surveillance systems to efficiently continue tracking COVID-19 after the PHE ends and will share more information when available.
  • The end of a public health emergency does not equate to the end of the current national vaccine distribution program or the availability of vaccine commercially. CDC has received many questions regarding commercializing COVID-19 vaccines. They continue to work with HHS on this process and are collecting questions to help ensure they address the needs of jurisdictions and partners.
  • CDC’s Amended Order Implementing Presidential Proclamation on Safe Resumption of Global Travel During the COVID-19 Pandemic will remain in effect until terminated by the president. It is implemented under a Presidential proclamation, Advancing the Safe Resumption of Global Travel During the COVID-19 Pandemic.

Data impacts
Reduced reporting of negative laboratory tests for SARS-CoV-2:
  • Context: Ending the PHE declaration would revoke the CARES Act authority for HHS to require laboratory result reporting. This could result in states and local authorities receiving less consistent and comprehensive of SARS-CoV-2 laboratory result data, which could also affect the quality of the data reported to CDC).
  • The change would likely primarily affect negative result reporting since laboratories and healthcare providers may still be required to report positive cases, depending on state and local laws or regulations.
  • This may impact speed of reporting, as case reporting can often lag behind test reporting data.
  • The change would not affect calculation of CDC COVID-19 Community Levels, but would impact the percent positivity metric used to understand Transmission Levels. Transmission Levels are used by hospitals, as mandated by Centers for Medicare & Medicaid Services (CMS) to determine prevention measures/mitigation strategies.
  • Impacts
  • Percent positivity metric will likely no longer be available.
  • COVID-19 Transmission Levels, used primarily for healthcare settings, would no longer be calculated, as they involve case and test positivity data.
  • CDC is determining how to address healthcare guidance without use of Transmission Levels.

Possible reduced submission of vaccine administration data from some jurisdictions:
  • Data Use Agreements (DUAs) for COVID-19 vaccine administration were established with termination provisions that reference the PHE. State and territorial public health jurisdictions are being asked to extend this DUA through the end of 2023:
  • As of April 5, 2023, 57 jurisdictions have signed a COVID-19 DUA extension for weekly reporting, 4 jurisdictions will provide data quarterly as part of submission of routine vaccine administration data, and 3 jurisdictions have not signed any DUA to enable sharing of COVID-19 vaccine administration data after the end of the PHE.
  • Impacts
  • Receipt of vaccine administration data would be unaffected for those with signed DUAs with CDC to share data.
  • CDC is discussing DUAs with other jurisdictions where they are not yet in place.
  • CDC is aware that some state policies (i.e., opt-in policies) that were paused due to the PHE will likely be reinstated and may affect vaccination providers’ ability to report vaccine administration to the state immunization information system (IIS). This could result in incomplete data at the IIS.
  • Without sharing of data from all jurisdictions, CDC will no longer have access to comprehensive data regarding who is being vaccinated. This will affect the ability to monitor implementation of vaccine recommendations, identify unvaccinated populations who may be susceptible to COVID-19, and evaluate vaccine effectiveness.

The cadence of COVID-19 hospitalization reporting may be reduced.
  • CMS currently requires daily hospital reporting of COVID-19 and other data elements. CDC is working closely with CMS and the Administration for Strategic Preparedness and Response (ASPR) to determine which data elements remain critical for public health, preparedness, and patient safety following the conclusion of the PHE—and the frequency with which these need to be reported.
  • More detail: CMS Conditions of Participation regulations currently require the current reporting of hospitalization data and bed occupancy to be reported to CDC every day during the PHE. In its FY 2023 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Final Rule (CMS-1771-F) released in August 2022, CMS finalized a revision to the hospital and critical access hospital (CAH) infection prevention and control conditions of participation (CoP) requirements that require hospitals and CAHs, after the conclusion of the current COVID-19 PHE, to continue reporting on a reduced number of COVID-19 data elements. The revisions will apply upon conclusion of the COVID-19 PHE and continue through April 30, 2024, unless the Secretary establishes an earlier ending date.   
  • Impacts
  • CDC is working closely with CMS and ASPR to determine which data elements remain critical for public health, preparedness, and patient safety following the conclusion of the PHE—and the frequency with which these need to be reported.
  • CDC will share any guidance related to reporting requirement changes when they are issued by CMS. 
  • Certain changes in hospitalization reporting might affect calculation of the COVID-19 Community Levels

Possible reduction in number of pharmacy testing sites
  • The ending of the PHE may limit the ability for the CDC Increasing Community Access to Testing (ICATT) for COVID-19 (cdc.gov) program to provide no-cost COVID-19 testing for communities who are at a greater risk of being impacted by the pandemic and people without health insurance.
  • Current federal agreements between pharmacies and ICATT will allow for continued no-cost COVID-19 testing of people who are uninsured; Although, the ICATT may have a reduction in COVID-19 testing locations after the PHE ends. 
  • ICATT pharmacy and surge testing vendors are funded for 6-month increments. Contracts are currently funded through May 2023. Funding beyond May 2023 will be announced as information becomes available.
  • Impacts
  • Changes in insurance reimbursement policies may reduce the number of ICATT vendor sites offering testing.
  • CDC will continue to support testing for people who are uninsured through the ICATT program, although testing access may be reduced if fewer testing sites are available.
  • Please send questions regarding ICATT to ICATTProgram@cdc.gov

The lifting of the PHE provides an opportunity for CDC to reassess COVID-19 surveillance more broadly. They are engaging in discussions with partners and developing communication on the potential strategic and operational changes.

Exposure Notification System
On May 11, 2023, in accordance with the expiration of the COVID-19 public health emergency declaration, the following components of the Exposure Notifications System in the United States will conclude:
  • National Key Server (NKS) and Multi-tenant Verification Server (MVS) Operations
  • Exposure Notifications Express (ENX) Solution

As a result, APHL will no longer be able to offer this service to any agency, including those utilizing Exposure Notifications Express, custom exposure notifications applications, or services that mirror the server.  
From the Administration
CMS: Enrollment data
Here is a quick snapshot of how many people of all ages are covered by Medicaid, CHIP and Medicare: Access to Health Coverage | CMS

ACL: President’s Committee for People with Intellectual Disabilities
The President's Committee for People with Intellectual Disabilities (PCPID) will hold a virtual meeting for members to discuss issues related to home- and community-based services (HCBS) that will be a part of the Committee’s Report to the President. All the PCPID meetings, in any format, are open to the public. This virtual meeting will be conducted in a discussion and presentation format with testimony from people with intellectual disabilities and other stakeholders to provide more information about their experiences with HCBS. View more details published in the Federal Register notice. Stakeholder input is very important to the PCPID. Comments and suggestions, especially from people with intellectual and developmental disabilities, are welcome at any time. If there are comments related to HCBS or other areas that you would like to inform the PCPID, please share them through this form on ACL.gov. Comments received by April 21st will be shared with the PCPID at the May 1st meeting.
Monday, May 1 | 12:00 - 5:00 pm ET Register for the meeting

Both ASL and CART will be provided during the meeting. If requesting accommodations for meeting participation, please send an email to jokim@sensisagency.com by April 17, 2023. 
Other CYSHCN Policy-Related Materials of Interest
Court Ruling: ACA and Preventive Services
Recently a federal District Court Judge in Texas struck down the ACA provision requiring most health plans to cover, with no cost sharing, preventive health screenings and services that receive an A or B recommendation from the U.S. Preventive Services Task Force (USPSTF).

To better understand Braidwood v. Becerra, consider reading this NHeLP blog or listening to this Tradeoff Podcast episode. This threat to the ACA is not immediate, as there will likely be more litigation, but it does reveal concerning information about the possible shape of future methods and efforts to dismantle the ACA.

Manatt Blog: AAP Guidelines for Obesity and Medicaid
The American Academy of Pediatrics (AAP) recently released new clinical practice guidelines on the evaluation and treatment of children with obesity. The new guidance, AAP’s first such update in 15 years, reflects a major change in clinical perspective on obesity: The AAP reframes obesity as a chronic disease—rather than a result of personal choices—carrying significant short- and long-term implications for children’s health, and highlights the importance of addressing it through early and intensive treatment.

The new guidance accompanies a broader, national increase in the focus on nutrition and health. In September 2022, the Biden-Harris Administration released their National Strategy on Hunger, Nutrition, and Health (see below for details in recent President’s budget supporting these programs) and hosted the first White House Conference on the topic in more than 50 years. Many related initiatives have since taken root at the federal, state and community levels. This work aims to address a growing epidemic, with nearly 1 in 5 children affected by obesity in the United States a, figure that has nearly quadrupled since the 1970s.

This Manatt article reviews the new AAP guidance, its implications for pediatric clinical practice, and the associated impacts on coverage and care delivery for children enrolled in Medicaid.

Nutrition and physical health programs in President’s FY 2024 Budget:
  • Provides Critical Nutrition to Children, Seniors, and Families: Provides $6.3 billion to fully fund WIC and $15 billion over ten years to expand the Community Eligibility Program, which provides free school meals to 9 million children
  • Strengthens the Supplemental Nutrition Assistance Program (SNAP): Highlights the Farm Bill as an opportunity strengthen SNAP by doing away with time limits, increasing cross enrollment capabilities, and expanding food purchasing options to include more healthy choices
  • Provide Better Care for All Americans: Provides $1.7 billion to expand Medicaid and Medicare’s nutrition and obesity counseling coverage
  • Makes the Healthy Choice the Easy Choice: Invests $478 million in the FDA’s Center for Food Safety and Applied Nutrition to improve food labeling and $26 million to raise awareness of dietary and physical activity guidelines
  • Builds Communities That Promote Physical Activity: Invests $130 million into the CDC’s Division of Nutrition, Physical Activity, and Obesity, which runs State Physical Activity and Nutrition (SPAN) programs, which aim to make physical activity safer and more accessible
  • Connects More Americans to Parks: Invests $7 million in the National Parks Service to create transit opportunities to provide equal access to parks and green spaces
  • Builds the Foundation for Evidence-Based Policies: Invests $121 million in nutrition research to create evidence-based policies

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Family Voices is a national organization and grassroots network of families and friends of children and youth with special health care needs and disabilities that promotes partnership with families--including those of cultural, linguistic and geographic diversity--in order to improve healthcare services and policies for children.