Georgia Medicaid Disaster and Emergency Flexibilities: A Complete Guide to Section 1135 Waivers, HCBS Appendix K, and Georgia Implementation

::: hero Georgia Medicaid Disaster and Emergency Flexibilities

When hurricanes hit the Georgia coast, when ice storms shut down north Georgia, when wildfires displace south Georgia residents, when COVID-19 reshapes everything for years at a time, when a tornado destroys medical infrastructure in a single afternoon, Medicaid needs to function in conditions for which the ordinary rules were not designed. A nursing home is evacuated and residents are scattered to facilities in three states. A dialysis patient cannot reach the regular clinic. A child with complex medical needs is in a shelter with no access to their home health team. A senior with dementia is in a temporary placement that the state agency has not enrolled. A pharmacy is destroyed and prescriptions need to be filled at another location. A doctor licensed in Alabama is providing care at a Georgia evacuation shelter.

Section 1135 of the Social Security Act, codified at 42 U.S.C. §1320b-5, was created to authorize HHS to waive or modify Medicare, Medicaid, and CHIP requirements during a public health emergency or major disaster. The HCBS Waiver Appendix K provides a parallel template for modifying home and community-based services waivers in emergencies. Together with Section 1812(f) for Medicare flexibility, Section 1115(a)(2) for 1115 waiver flexibility, and various other authorities, these provisions form the federal emergency framework.

This guide translates Georgia's emergency Medicaid framework for families. We walk through the federal architecture, explain how Section 1135 waivers work in practice, describe Georgia's coordination among DCH, GEMA, DPH, local emergency management agencies, and CMS Region IV, and discuss the specific flexibilities Georgia has invoked across recent emergencies including Hurricane Matthew (2016), Hurricane Irma (2017), Hurricane Michael (2018), the COVID-19 PHE (2020-2023), Hurricane Idalia (2023), and Hurricane Helene (2024). The goal is to demystify a system that becomes urgent precisely when families have the least bandwidth for understanding policy frameworks.

If you are in an active emergency and need help: call DCH Member Services at 1-866-211-0950, GEMA at 1-800-879-4362, or 211 Georgia (dial 211) for shelter, transportation, and emergency resources. For nursing home evacuation concerns, call the Georgia Long-Term Care Ombudsman at 1-866-552-4264. :::

::: callout Key takeaways

1. Section 1135 SSA is the keystone. Codified at 42 U.S.C. §1320b-5, it authorizes HHS to waive or modify Medicare, Medicaid, and CHIP requirements during emergencies.
2. Two predicate declarations are needed. A Section 319 PHE declaration by the HHS Secretary plus a Stafford Act major disaster declaration by the President (or National Emergencies Act declaration).
3. HCBS Appendix K is the parallel template. Allows modifications to Section 1915(c) HCBS waivers during emergencies, including family caregiver payment, remote service delivery, and extended assessments.
4. Common flexibilities include. Provider enrollment streamlining, prior authorization waiver, level-of-care assessment extension, fair hearing timeline extension, telehealth expansion, pharmacy flexibility, and EMTALA modifications.
5. Georgia has invoked Section 1135 multiple times. Hurricane Matthew (2016), Hurricane Irma (2017), Hurricane Michael (2018), COVID-19 (2020-2023), Hurricane Idalia (2023), Hurricane Helene (2024).
6. DCH coordinates with GEMA, DPH, and CMS Region IV. State emergency response and federal Section 1135 implementation operate through established coordination.
7. Members should plan ahead. Keep Medicaid cards accessible, maintain medication supplies, register for utility special-needs programs if power-dependent, and know how to reach 211 Georgia.
8. Wind-down periods are real. Emergency flexibilities terminate on schedules, and members should monitor for resumption of ordinary requirements. :::

The federal statutory foundation

By Brevy Care Team · Last verified May 12, 2026

The federal emergency Medicaid framework rests on a small number of statutory provisions that work together. Understanding the architecture matters because emergency response moves fast, and knowing which lever can be pulled saves time and reduces uncertainty.

Section 1135 SSA: the keystone provision

Section 1135 of the Social Security Act, codified at 42 U.S.C. §1320b-5, authorizes the Secretary of Health and Human Services to waive or modify Medicare, Medicaid, and CHIP requirements as the Secretary determines appropriate during a public health emergency or major disaster.

Two predicate conditions must be met to trigger full Section 1135 authority:

A Section 319 PHE declaration. The HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act (42 U.S.C. §247d). Section 319 declarations last for 90 days and can be renewed. For COVID-19, Section 319 declarations were renewed repeatedly from January 2020 through May 2023.

A Stafford Act declaration or National Emergencies Act declaration. The President declares a major disaster or emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (42 U.S.C. §5121 et seq.) or a national emergency under the National Emergencies Act (50 U.S.C. §1601 et seq.).

The dual predicate is intentional. The Section 319 PHE alone authorizes some flexibilities; the Stafford Act alone authorizes other emergency authorities; the combination triggers full Section 1135 authority.

For hurricanes affecting Georgia, the Stafford Act declaration typically follows GEMA's request and the Governor's request to the President. For pandemics like COVID-19, both Section 319 and Stafford Act declarations have been issued. For localized emergencies that do not rise to Presidential disaster declaration, Section 1135 may not be fully available, but other authorities can still provide flexibility.

What Section 1135 authorizes

Once invoked, Section 1135 authorizes HHS (acting through CMS) to:

• Waive conditions of participation, certification, or licensure requirements for providers. Examples: allowing out-of-state physicians to deliver care at Georgia shelters, allowing emergency licensure for nurses crossing state lines, allowing temporary modifications to nursing home certification requirements.
• Waive prior authorization requirements for Medicaid services. Examples: suspending prior authorization for hospital admissions, skilled nursing facility admissions, home health, DME, or specialty referrals.
• Modify or waive deductibles, copayments, coinsurance, and similar cost-sharing. For Medicaid, copayments may be suspended for services related to the emergency.
• Permit out-of-state providers to deliver Medicaid services without state Medicaid enrollment. Critical when members are evacuated to other states.
• Modify deadlines for fair hearings, redeterminations, and similar procedural matters. Members are not penalized for missed deadlines during emergencies.
• Waive program integrity requirements that would impede emergency response, with safeguards.
• Waive sanctions for noncompliance resulting from the emergency.
• Modify level-of-care assessment timelines for nursing facility and HCBS services. Critical for evacuated residents who cannot complete in-person assessments on schedule.
• Waive the three-day prior hospitalization requirement for skilled nursing facility coverage under Medicare (analog applies in some Medicaid contexts).
• Suspend EMTALA penalties in limited circumstances when patient screening is modified.

Section 1812(f) SSA: Medicare emergency flexibility

Section 1812(f) provides parallel flexibility on the Medicare side, particularly for skilled nursing facility services. CMS often coordinates Section 1135 (Medicare-Medicaid joint) and Section 1812(f) (Medicare-only) flexibilities together.

Section 1115(a)(2) SSA: emergency 1115 modifications

States with existing 1115 demonstration waivers can modify them during emergencies. Pre-existing budget neutrality and other constraints may be relaxed.

Section 1115A SSA: CMMI emergency authority

The Center for Medicare and Medicaid Innovation can deploy alternative payment models with emergency flexibility.

HCBS Appendix K: modifying 1915(c) waivers in emergencies

For HCBS waivers operated under Section 1915(c) SSA, CMS has developed Appendix K as a standardized template for emergency modifications. Appendix K allows states to amend their HCBS waivers during emergencies to:

• Add settings where services can be delivered. Homes of evacuees, shelters, hotels, temporary placements.
• Allow family caregivers to be paid for services that would otherwise be unpaid. Critical when professional caregivers cannot reach members during evacuations.
• Extend level-of-care reassessment timelines. Members do not lose HCBS eligibility because emergency conditions prevent timely reassessment.
• Modify person-centered planning timelines. Plans of care can be extended without immediate revision.
• Modify provider qualifications temporarily. Allows expedited training or substitution of provider categories.
• Authorize remote service delivery. Telehealth for HCBS services that ordinarily require in-person delivery.
• Authorize 24-hour facility-based respite without otherwise meeting institutional level of care. Useful when family caregivers need emergency respite due to disaster displacement.
• Modify service definitions to allow flexibility in how authorized services are delivered.

Appendix K amendments are typically time-limited (lasting through the emergency plus a wind-down period) and are routinely approved by CMS during declared emergencies. Georgia has approved Appendix K amendments for SOURCE, CCSP, NOW, COMP, ICWP, and GAPP across multiple emergencies.

Federal regulations

42 CFR 430.20 et seq.

Federal regulations on federal financial participation in state Medicaid expenditures, including provisions for FFP during emergencies and disasters.

42 CFR 431.231

Reinstatement after disaster. Provides framework for reinstating beneficiaries to coverage and addressing redetermination after emergencies. Important for members whose eligibility lapses during displacement.

42 CFR 431.10 and 431.16

Single state agency responsibility, including emergency operations. The state Medicaid agency (DCH in Georgia) retains overall responsibility even during emergencies.

42 CFR Part 438 Subpart H

Provisions addressing managed care plan obligations during emergencies, including continuity-of-care and access requirements. Managed care plans must continue serving members displaced to other regions.

CMS guidance and templates

CMS Section 1135 waiver request templates

CMS provides standardized templates and checklists for state Section 1135 waiver requests. The templates cover:

• Provider enrollment flexibility request
• Prior authorization flexibility request
• Level-of-care assessment flexibility request
• Fair hearing timeline flexibility request
• HCBS waiver Appendix K request
• EMTALA flexibility request

States complete the relevant templates and submit to CMS Region IV (Atlanta) for Georgia. Approval is typically rapid (often within days) during active emergencies. CMS publishes approved waivers on its website.

CMS State Medicaid Director Letters

• SMD 09-013 (H1N1): established early framework for Section 1135 waivers.
• Multiple SMDs on COVID-19 (2020-2023): detailed Section 1135 framework, Appendix K templates, PHE unwinding plans.
• SMDs on subsequent emergencies addressing specific flexibility issues.

The CMS guidance has evolved continuously. The COVID-19 PHE produced the most extensive federal guidance to date, and many of the lessons learned have been incorporated into post-COVID frameworks.

The COVID-19 PHE and what it taught us

The COVID-19 Public Health Emergency (January 31, 2020 through May 11, 2023) was the largest test of the Section 1135 framework in its history. The lessons are now baked into how Georgia and other states prepare for emergencies.

Scale of flexibilities

CMS approved hundreds of Section 1135 waivers and HCBS Appendix K amendments across all 50 states. Virtually every state used multiple flexibilities. Common COVID-era flexibilities included:

• Provider enrollment streamlining (allowing out-of-state providers and reducing screening requirements)
• Prior authorization suspension for many services
• Telehealth flexibility (allowing telehealth for services that historically required in-person)
• HCBS service flexibility (allowing family caregiver payment, remote service delivery)
• Level-of-care reassessment extension
• Renewal extension and continuous enrollment (under separate FFCRA authority)
• EMTALA flexibility
• Pharmacy refill flexibility
• Provider documentation modifications

Families First Coronavirus Response Act (P.L. 116-127)

FFCRA Section 6008 provided enhanced FMAP to states (6.2 percentage points additional federal match) on condition that states maintain continuous enrollment during the PHE. This effectively suspended Medicaid disenrollment for the duration of the PHE. Georgia received approximately $1.5 billion in enhanced FMAP across the PHE period.

CARES Act (P.L. 116-136)

CARES Act Section 3201 et seq. provided additional Medicaid flexibility, telehealth expansion, and provider relief.

Consolidated Appropriations Act 2023 (P.L. 117-328)

CAA 2023 Section 5131 et seq. addressed the wind-down of PHE-era continuous enrollment, establishing the "unwinding" process that ran from April 2023 through 2024. States had to redetermine eligibility for everyone enrolled during the PHE.

Telehealth permanence

Many telehealth flexibilities introduced during the PHE have been made permanent or extended through subsequent legislation. Telehealth in Medicaid is now considerably more flexible than pre-pandemic.

Lessons for future emergencies

The COVID PHE demonstrated:

• Section 1135 framework can be scaled to massive, prolonged emergencies
• Appendix K is essential for HCBS continuity
• Telehealth flexibility is critical for ongoing care continuity
• Continuous enrollment can prevent coverage churn during crises
• Provider enrollment flexibility enables out-of-state surge capacity
• Documentation requirements can be safely modified
• Federal-state coordination must be rapid and ongoing
• Member communication during emergencies is critical

Georgia's emergency Medicaid history

Hurricane Matthew (October 2016)

Major hurricane affecting the Georgia coast. Coastal counties evacuated. Section 1135 waivers approved for evacuation-related provider flexibility, prior authorization waiver, and Appendix K HCBS amendments. Nursing home evacuations occurred along the coast.

Hurricane Irma (September 2017)

Statewide hurricane impact (storm crossed full state from Florida). Massive evacuation from Florida into Georgia. Section 1135 waivers approved for similar flexibilities plus extensions for evacuees displaced from Florida. Georgia coordinated with Florida Medicaid for cross-state continuity.

Hurricane Michael (October 2018)

Catastrophic Category 5 hurricane impacting southwest Georgia (Albany, Bainbridge, southwest Georgia agricultural region). Damage was severe and recovery prolonged. Section 1135 waivers approved for displaced Medicaid beneficiaries, nursing home evacuations, HCBS continuity, and provider flexibility. The southwest Georgia healthcare infrastructure was substantially affected.

COVID-19 PHE (March 2020 through May 2023)

Most extensive use of Section 1135 in Georgia history. Multiple rounds of waiver requests, Appendix K amendments, continuous enrollment under FFCRA, and PHE unwinding through 2024. Telehealth flexibility was particularly important. Hospital surge capacity, ventilator allocation, and provider capacity issues drove many flexibilities.

Hurricane Idalia (August 2023)

Hurricane affecting south Georgia. Section 1135 waivers approved for evacuation, provider flexibility, and HCBS continuity. Coastal and south Georgia counties affected.

Hurricane Helene (September 2024)

Severe hurricane affecting south and central Georgia. Damage was widespread including in inland counties not historically affected by hurricanes. Section 1135 waivers approved for widespread displacement, infrastructure disruption, and ongoing recovery. Recovery extended through 2025.

Other emergencies

• Winter storms and ice storms. Recurring events affecting north Georgia, sometimes statewide. Section 1135 flexibility for short-duration disruption of care.
• Tornado outbreaks. Newnan tornado (March 2021) destroyed substantial property and disrupted care for affected residents.
• Wildfires. South Georgia wildfires (2017 and others) caused localized disruption.
• Flooding events. Recurring events.
• Severe thunderstorm outbreaks. Recurring events.

Georgia emergency infrastructure

Georgia Emergency Management Agency (GEMA)

State agency with statutory authority for emergency response under O.C.G.A. §38-3-1 et seq. GEMA coordinates state response and serves as primary liaison to FEMA. GEMA hotline 1-800-879-4362. GEMA also operates the Georgia Emergency Operations Center.

Georgia Emergency Operations Plan

Statewide plan establishing roles and protocols for state agencies during emergencies. DCH has specific responsibilities under the plan, including continuity of Medicaid operations, coordination with managed care plans, and member outreach.

DCH Emergency Operations

DCH maintains an Emergency Operations function that activates during declared emergencies. Functions include:

• CMS coordination for Section 1135 waivers
• Coordination with managed care plans (Amerigroup, Peach State, CareSource)
• Communication with providers
• Member outreach during emergencies
• Coordination with GEMA and DPH
• Continuity of operations for eligibility determinations and renewals

Department of Public Health emergency operations

DPH operates a Public Health Emergency Operations Center that coordinates public health response to emergencies and disasters. DPH plays particularly important roles in pandemics, foodborne illness outbreaks, and other public health emergencies.

Local emergency management agencies

Each Georgia county has a local emergency management agency. These coordinate local response and serve as primary contact for residents during local emergencies. Members in shelters may need Medicaid-related support during their displacement.

Georgia State Medical Association emergency physician registry

GSMA maintains a registry of physicians available for emergency deployment. This dovetails with Section 1135 provider enrollment flexibility for surge capacity.

Georgia Composite Medical Board emergency licensure

The Board has authority to grant emergency licensure to out-of-state physicians during declared emergencies. This works alongside Section 1135 provider enrollment flexibility.

Georgia Long-Term Care Ombudsman during evacuations

The Georgia Long-Term Care Ombudsman (1-866-552-4264) plays a critical role during nursing home evacuations, supporting residents and families during displacement. The ombudsman has authority to advocate for residents and intervene with facilities.

How Section 1135 waivers work in practice

The Section 1135 process moves fast during emergencies. Here is the typical sequence.

Step 1: Predicate declarations

A Section 319 PHE declaration by the HHS Secretary AND a Stafford Act major disaster declaration by the President (or a National Emergencies Act declaration). For pandemics like COVID-19, both have been issued. For natural disasters affecting Georgia, the Stafford Act declaration follows GEMA's request, the Governor's declaration, and the formal request to the President.

For sub-Presidential emergencies (a Governor's state of emergency without federal declaration), Section 1135 may not be fully available. Some flexibilities can still operate under state authority or under DCH's own discretion.

Step 2: State request to CMS

DCH submits Section 1135 waiver requests to CMS Region IV (Atlanta) using CMS-provided templates. The state Medicaid director typically signs the request. Requests can include:

• Provider enrollment flexibility
• Prior authorization waiver
• Level-of-care assessment extension
• Fair hearing timeline extension
• HCBS Appendix K amendments
• Continuity of care provisions
• Telehealth flexibility
• Pharmacy flexibility
• Documentation modifications

Step 3: CMS approval

CMS typically approves within days during active emergencies. CMS publishes approved waivers on its website. CMS may issue blanket waivers covering all states simultaneously (this happened during COVID) or state-specific waivers based on individual requests.

Step 4: Implementation

DCH implements the approved flexibilities, communicating with:

• Medicaid managed care plans (operational instructions)
• Provider networks (bulletins and provider portal notices)
• Hospital systems (joint communications)
• Nursing facilities (regulatory bulletins)
• HCBS providers (case management coordination)
• Pharmacies (pharmacy bulletins)
• Members (211, traditional media, social media, direct outreach where feasible)

Step 5: Operations during emergency

DCH operates with modified rules. Providers can deliver care under the flexibilities. Members receive care notwithstanding ordinary requirements. The managed care plans implement the modifications for their members.

Step 6: Wind-down

After the emergency, flexibilities terminate on a schedule. Some flexibilities have permanent extensions through subsequent rulemaking; most return to ordinary requirements. Members and providers must monitor for the return of usual rules.

Step 7: Recoupment and audit

CMS may audit emergency-period payments to ensure compliance with the modified rules. Provider documentation requirements during emergencies are typically reduced but not eliminated; subsequent reconciliation can occur. Members are generally not subject to recoupment for emergency-era care.

Common Section 1135 flexibilities in Georgia

Provider enrollment flexibility

Allows out-of-state providers to deliver Medicaid services to Georgia members displaced to other states (or to deliver services in Georgia under emergency licensure). Examples:

• Florida providers serving Georgia evacuees in Florida
• Alabama providers serving Georgia evacuees in Alabama
• South Carolina providers serving Georgia coastal evacuees
• Out-of-state physicians serving at Georgia shelters under Georgia Composite Medical Board emergency licensure

Prior authorization waiver

Suspends prior authorization requirements for specific services during the emergency. Common categories:

• Inpatient hospital admissions (for emergency-related conditions)
• Skilled nursing facility admissions (for evacuees needing temporary placement)
• Home health services (for displaced members needing services in temporary settings)
• DME (for replacement equipment for evacuees)
• Specialty referrals
• Behavioral health services
• Some pharmaceuticals

Level-of-care assessment extension

Extends the deadline for reassessment of level of care for nursing facility and HCBS services. Critical for evacuated nursing home residents who cannot complete in-person reassessments on the usual schedule.

Fair hearing timeline extension

Extends deadlines for fair hearings and related procedural matters. Members are not penalized for missing deadlines during emergencies. Pending hearings may be rescheduled or held remotely.

HCBS Appendix K flexibility

The most extensive emergency flexibility for HCBS. Allows:

• Service delivery in evacuee shelters and temporary housing
• Family caregiver payment that ordinarily would not be allowed (critical when professional caregivers cannot reach members)
• Remote service delivery via telehealth
• Extended level-of-care reassessment
• Modified provider qualifications temporarily
• 24-hour facility-based respite without institutional LOC

Telehealth flexibility

Allows expanded telehealth delivery, including for services that ordinarily require in-person delivery (mental health, primary care, specialty care, some HCBS services). Phone-only services may be authorized where video is impractical.

Pharmacy flexibility

Allows early refills of prescriptions, dispensing without prior authorization for certain medications, and out-of-state pharmacy fills for displaced members.

EMTALA flexibility

Allows hospitals to direct patients to alternative locations and modify on-site screening procedures in narrow circumstances during emergencies. This is among the most carefully scrutinized flexibilities because patient protection concerns are paramount.

Continuity of care provisions

Managed care plans must continue serving members displaced to other regions or states. Out-of-network coverage applies at in-network rates for emergency-related care.

Coordination with state emergency authorities

Georgia Governor's emergency declarations

O.C.G.A. §38-3-22 authorizes the Governor to declare a state of emergency. The Governor's declaration is typically the precursor to the request for federal Stafford Act declaration. The Governor's declaration alone activates state emergency authorities (including some DCH emergency operations).

GEMA coordination

GEMA coordinates state response. DCH operations during emergencies are coordinated through GEMA's incident command structure under the National Incident Management System (NIMS) framework.

Local emergency management

Local emergency management agencies coordinate evacuation, shelter operations, and other local response. Members in shelters may need Medicaid-related support during their displacement. DCH coordinates with local agencies through GEMA.

Interstate compacts

Several interstate compacts facilitate cross-state emergency response, including:

• Emergency Management Assistance Compact (EMAC) for emergency personnel and resources
• Interstate Compact on the Placement of Children for cross-state child welfare placements
• Various professional licensure compacts for emergency professional services (Nurse Licensure Compact, Physical Therapy Compact, etc.)

Mutual aid arrangements

Georgia has mutual aid arrangements with neighboring states (Florida, Alabama, South Carolina, Tennessee, North Carolina) for cross-state emergency response.

Family-facing considerations during emergencies

Medicaid card and proof of coverage

Members should keep their Medicaid card (digital or physical) accessible during evacuations. DCH can verify eligibility electronically if the card is lost. Many members have access to digital Medicaid cards through the Georgia Gateway portal.

Prescription evacuation planning

Members on chronic medications should have:

• A 30-day supply available
• A list of medications with dosages and prescribers
• A list of pharmacy locations they can use
• Awareness of mail-order pharmacy options
• An emergency contact in their preferred pharmacy chain

HCBS service contingency

Members receiving HCBS should discuss emergency contingency planning with their case managers in advance. Many HCBS providers have emergency protocols. Family caregivers should know:

• The HCBS waiver program's emergency protocols
• The case manager's emergency contact
• Substitute caregivers (if available)
• The Appendix K family caregiver payment option (when invoked)

Nursing home evacuation rights

Nursing home residents have protections under 42 CFR 483.15 (transfer and discharge) and 42 CFR 483.30 (care plans) even during evacuations. Families should:

• Know where their loved one is at all times during evacuation
• Verify that the receiving facility can meet care needs
• Ensure medication continuity
• Engage the Long-Term Care Ombudsman (1-866-552-4264) if concerns arise
• Understand that bed-hold rules continue to apply (Medicaid maintains the original bed for return)

Dialysis emergency

End-stage renal disease patients have special emergency protocols. The Forum of ESRD Networks (Network 14 covers Georgia) coordinates dialysis emergency response. Patients should:

• Register with their dialysis facility for emergency notification
• Have a Patient Information Sheet ready for use at any dialysis facility
• Know the locations of dialysis facilities along potential evacuation routes
• Plan for travel time to ensure dialysis schedule maintenance

Power-dependent equipment

Members using power-dependent equipment (oxygen concentrators, CPAP, ventilators, infusion pumps, motorized wheelchairs) should:

• Register with their utility company's special needs program
• Have backup power plans (generators, battery backup)
• Know the locations of medical equipment hubs that can provide replacement equipment
• Maintain a list of equipment with serial numbers and prescriber information

Transportation during emergencies

Medicaid Non-Emergency Medical Transportation (NEMT) may be unavailable during emergencies. Members should have alternative plans for ongoing transportation needs.

211 Georgia

211 Georgia is a primary information resource during emergencies. Members can call 211 for:

• Shelter locations
• Food assistance
• Transportation
• Medication assistance
• Mental health support
• General emergency information

Wind-down of emergency flexibilities

Each emergency has a wind-down period after the formal declaration ends. Wind-down includes:

• Termination of provider enrollment flexibilities (with grandfather provisions for ongoing care)
• Resumption of prior authorization requirements
• Resumption of level-of-care reassessment
• Resumption of fair hearing deadlines
• Termination of HCBS Appendix K provisions (with phased transition)
• Termination of telehealth flexibilities (some have been made permanent)

The COVID PHE wind-down was particularly extensive, occurring through 2023-2024 with the CAA 2023 framework. Members were notified of their renewal due dates and given opportunities to provide updated information. Approximately 25 percent of Georgia Medicaid members ultimately lost coverage during unwinding (though many requalified).

Worked examples

These examples illustrate how disaster flexibilities operate in practice.

Eleanor, 78, coastal Brunswick: Hurricane Idalia nursing home evacuation

Eleanor lives at a 90-bed nursing home in coastal Brunswick, Georgia. As Hurricane Idalia approaches the southeast coast in late August 2023, GEMA issues a mandatory evacuation order for Glynn County coastal areas. The nursing home administrator coordinates with sister facilities and evacuates all 90 residents to inland facilities in Macon, Atlanta, and Tifton.

How disaster flexibilities operate: Eleanor is transferred to a Macon facility that does not have her on its census but has an open bed. Under Section 1135 provider enrollment flexibility and HCBS Appendix K-style emergency provisions, the receiving facility is authorized to provide care. The Brunswick facility maintains its Medicaid bed-hold for Eleanor (continuing to receive Medicaid payment for her room at the original facility while she is displaced). The Macon facility receives an emergency payment for her care.

Eleanor's care team coordinates with the Macon facility. Medication orders are reconciled. Care plan is shared. The Georgia Long-Term Care Ombudsman makes contact with Eleanor and her family to ensure continuity.

After the storm, Eleanor returns to her Brunswick facility. The transition back is managed by both facilities. Eleanor experienced significant disruption but maintained continuous Medicaid coverage and continuous care because of Section 1135 flexibility.

Marcus, 45, north Georgia: ice storm interrupting home dialysis

Marcus has end-stage renal disease and receives in-center hemodialysis three times weekly at a clinic in Toccoa. A major ice storm in February cuts power across north Georgia for several days. The Toccoa dialysis center loses power. Marcus needs dialysis to survive.

How disaster flexibilities operate: The Georgia ESRD network (Network 14) activates emergency protocols. Marcus is referred to a dialysis facility in Gainesville (Northeast Georgia Medical Center area) that has power. Under Section 1135 provider enrollment flexibility, Marcus can receive dialysis at the alternative facility even though it is not his usual provider. Medicaid covers the service.

Transportation is arranged by Marcus's neighbors (NEMT is unavailable due to the storm). The Gainesville facility verifies Marcus's coverage through the Georgia Gateway portal and provides three dialysis sessions until power is restored to Toccoa.

Marcus returns to his usual Toccoa facility after power restoration. The Section 1135 flexibility ensured that Marcus did not miss critical dialysis treatments during the storm.

Aisha, 32, Savannah: Hurricane Helene late-pregnancy evacuation

Aisha is 36 weeks pregnant when Hurricane Helene approaches Savannah in late September 2024. Her OB is at Memorial Health Savannah. Mandatory evacuation is ordered for Chatham County. Aisha and her family evacuate to Atlanta, planning to stay with relatives.

How disaster flexibilities operate: Aisha goes into preterm labor in Atlanta and presents at Northside Hospital. Northside is not in her Medicaid managed care plan's primary network for Savannah, but under Section 1135 emergency continuity-of-care provisions, the plan covers the out-of-network care at in-network rates.

Aisha delivers at Northside. Her son is delivered at 36 weeks with no major complications. Northside provides standard newborn care. Both Aisha and her son are covered by Medicaid throughout, with no preauthorization required for the emergency-related care.

After discharge, Aisha returns to Savannah after the storm and resumes care at Memorial Health. The managed care plan transitions her son's pediatric care to a Savannah pediatrician.

Jamil, 8, Newnan tornado: pediatric complex care disruption

Jamil has complex congenital syndrome and receives extensive home health, equipment, and therapies. He attends school with significant accommodations. In March 2021, an EF-3 tornado destroys substantial portions of Newnan, including the school complex Jamil attended and the home health agency's local office.

How disaster flexibilities operate: Section 1135 was not formally invoked for the Newnan tornado (which was a state emergency rather than a federal disaster). However, DCH used its own administrative flexibility to:

• Authorize Jamil's home health services through an alternative agency
• Extend prior authorization on therapy services
• Permit equipment replacement without ordinary documentation
• Extend the level-of-care reassessment

Jamil's family also benefited from Appendix K-style flexibility under the GAPP program (which had been amended during COVID and still had some flexible provisions). The combination of administrative flexibility and remaining COVID-era HCBS flexibility supported continuity for Jamil's complex care.

Diana, 84, rural Bulloch County: ice storm interrupting home health

Diana lives in rural Bulloch County with her daughter Karen as primary caregiver. Diana receives twice-weekly home health visits for wound care and skilled assessment. A severe ice storm in January closes roads in rural Bulloch for four days. Diana's home health agency cannot reach her.

How disaster flexibilities operate: DCH's emergency administrative flexibility (used even without formal Section 1135 invocation for localized emergencies) authorizes:

• Karen to perform basic wound care under telehealth supervision from the home health agency
• The agency to bill for telehealth supervision time during the disruption
• Extended visit scheduling without re-authorization

After roads clear, the home health agency resumes in-person visits. The combination of Karen's emergency caregiving and the agency's telehealth supervision maintained Diana's care during the storm.

Tasha's father, 70, Albany: Hurricane Idalia interstate dementia displacement

Tasha's father has advanced Alzheimer's dementia and lives in a memory care unit at a nursing facility in Albany. Hurricane Idalia approaches in August 2023 and Tasha decides to evacuate her father to family in Tallahassee, Florida (closer family support during the storm).

How disaster flexibilities operate: Section 1135 flexibility permits the Albany facility to coordinate the transfer with a Florida facility that has temporary capacity. The Georgia-Florida interstate cooperation includes:

• Florida Medicaid emergency placement authorization
• Georgia DCH maintaining the original Medicaid bed-hold in Albany
• Cross-state continuity through CMS Region IV coordination
• Medication record transfer
• Care plan transfer

Tasha's father stays at the Florida facility for two weeks. During this time, his Medicaid eligibility remains intact in Georgia. After the storm, he returns to Albany.

The interstate coordination during dementia evacuations is particularly challenging because patients with dementia are especially vulnerable to disruption. The Section 1135 flexibility and the cooperation between states are what made this evacuation possible.

Frequently asked questions

::: accordion Q: What is Section 1135?

Section 1135 of the Social Security Act, codified at 42 U.S.C. §1320b-5, authorizes HHS to waive or modify Medicare, Medicaid, and CHIP requirements during a public health emergency or major disaster.

Q: When does Section 1135 apply?

When the HHS Secretary declares a Section 319 PHE and the President declares a Stafford Act major disaster (or National Emergencies Act emergency). Both predicate declarations are typically needed for full Section 1135 authority.

Q: What kinds of flexibilities does Section 1135 allow?

Provider enrollment streamlining, prior authorization waiver, level-of-care assessment extension, fair hearing timeline extension, HCBS Appendix K amendments, telehealth flexibility, pharmacy flexibility, EMTALA modifications, and others.

Q: What is HCBS Appendix K?

A standardized CMS template for amending Section 1915(c) HCBS waivers during emergencies. Allows family caregiver payment, remote service delivery, extended assessments, and other flexibilities.

Q: What emergencies has Georgia invoked Section 1135 for?

Hurricane Matthew (2016), Hurricane Irma (2017), Hurricane Michael (2018), COVID-19 PHE (2020-2023), Hurricane Idalia (2023), Hurricane Helene (2024), and others.

Q: My family member is being evacuated from a nursing home. What protections apply?

Federal transfer protections at 42 CFR 483.15 apply during evacuations. The facility must coordinate the transfer, ensure the receiving facility can meet needs, share records, and maintain the bed-hold (so the resident can return). The Georgia Long-Term Care Ombudsman (1-866-552-4264) can support residents and families during evacuations.

Q: My doctor is evacuated to another state during an emergency. Can I still get care?

Yes. Section 1135 provider enrollment flexibility allows out-of-state providers to deliver Medicaid services to Georgia members. Your managed care plan should cover the out-of-state care at in-network rates during the emergency.

Q: My HCBS services are interrupted because of an emergency. What can I do?

Contact your case manager. Under HCBS Appendix K flexibility, family caregivers may be paid, services may be delivered remotely, and other adaptations are possible. The Georgia ADRC (1-866-552-4464) can also help.

Q: My pharmacy is destroyed. How do I get my prescriptions?

Under Section 1135 pharmacy flexibility, other pharmacies can fill your prescriptions. Out-of-state pharmacies can also serve evacuated members. Contact DCH Member Services (1-866-211-0950) or call 211 for help finding an alternative pharmacy.

Q: Can I get telehealth during an emergency?

Yes. Section 1135 telehealth flexibility expands telehealth coverage during emergencies. Many telehealth flexibilities introduced during COVID have been made permanent.

Q: What happens to my Medicaid coverage if I'm displaced for weeks?

Section 1135 and 42 CFR 431.231 protect your coverage during displacement. Your eligibility continues. Renewal deadlines may be extended.

Q: What if I miss a fair hearing because of an emergency?

Section 1135 timeline extensions protect you. Hearings can be rescheduled. You will not be defaulted for missing a deadline because of an emergency.

Q: What about copayments during emergencies?

Section 1135 can authorize waiver of copayments for emergency-related services. Specific copayment status depends on the particular waivers approved.

Q: How does Section 1135 interact with managed care?

Managed care plans implement Section 1135 flexibilities for their members. Plans must continue serving members displaced to other regions and provide continuity of care. 42 CFR Part 438 Subpart H addresses managed care emergency obligations.

Q: What was the COVID PHE Section 1135 process?

CMS approved hundreds of Section 1135 waivers, often through blanket waivers that automatically applied to all states. Georgia layered specific state requests on top of the blanket waivers. The PHE lasted from January 2020 through May 2023.

Q: What was PHE unwinding?

The CAA 2023 process for redetermining eligibility for everyone enrolled during the COVID PHE. States had to complete redeterminations for all members, with significant numbers losing coverage. Georgia's unwinding ran from April 2023 through 2024.

Q: Are there always Section 1135 flexibilities during emergencies?

Section 1135 requires both Section 319 PHE declaration and Presidential disaster/emergency declaration. Some emergencies (Governor's declarations only, localized events) do not trigger Section 1135. However, DCH can use other administrative flexibilities even without formal Section 1135 invocation.

Q: What is the Long-Term Care Ombudsman?

A federally and state-funded advocacy program for nursing home and assisted living residents. The Georgia Long-Term Care Ombudsman (1-866-552-4264) is critical during evacuations and emergencies affecting LTC facilities.

Q: How do I prepare my family member for emergencies?

Maintain a 30-day medication supply, keep Medicaid card accessible, register power-dependent equipment with utility special-needs programs, know shelter locations, have emergency contacts for all providers, and have an evacuation plan.

Q: What is 211 Georgia?

A free information and referral service. Dial 211 from any phone. Operators can connect callers to shelter, food, medication, transportation, and other emergency resources.

Q: What is Brevy's role here?

Brevy is a national eldercare resource. We translate complex federal and state policy frameworks like Section 1135 emergency flexibilities into family-readable guides at brevy.com. We do not provide emergency response services; for emergencies, call 911, GEMA at 1-800-879-4362, or 211 Georgia. This guide is general information, not legal advice. :::

Key contacts

::: cta Georgia Medicaid emergency contacts

For active emergencies, call 911 first. For non-emergency assistance during a declared emergency:

• GEMA: 1-800-879-4362
• 211 Georgia: dial 211
• DCH Medicaid Member Services: 1-866-211-0950
• DPH Emergency Operations Center: through DPH main line
• CMS Region IV (Atlanta): through CMS main line

For long-term care and HCBS emergencies:

• Georgia Long-Term Care Ombudsman: 1-866-552-4264
• ADRC: 1-866-552-4464
• Disability Rights Georgia: 404-885-1234

For travel and disaster recovery:

• 511 Georgia (travel information): dial 511
• FEMA: 1-800-621-3362
• Red Cross Georgia: 1-844-280-5476
• Georgia Department of Insurance (storm-related): 1-800-656-2298

For caregiver support:

• AARP Caregiver Support: 1-877-333-5885
• 211 Georgia for caregiver resources: dial 211 :::

Brevy is committed to translating eldercare policy for the families who depend on it. Visit brevy.com for related guides on Medicaid HCBS waivers, nursing home rights, managed care, and emergency Medicaid.

This article is for general information only and is not legal, tax, or medical advice. Emergency flexibilities are time-limited and depend on specific declarations. Verify the current Section 1135 status, the specific approved flexibilities, and applicable deadlines directly with DCH or qualified counsel before acting on any specific matter.