The Coronavirus Aid, Relief, and Economic Security Act: Summary of Key Health Provisions

On March 27, 2020, the Coronavirus Aid, Relief, and Economic Security (CARES) Act was signed into law, marking the third and largest major legislative initiative to address COVID-19 to date. (The first was the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, signed into law on March 6, followed by the Families First Coronavirus Response Act, signed into law on March 18.) The CARES Act contains a number of health-related provisions focused on the outbreak in the United States, including paid sick leave, insurance coverage of coronavirus testing, nutrition assistance, and other programs and efforts. It also includes support for the global response. Highlights are provided below, followed by summaries of provisions in the tables; not included are provisions that are not closely related to health but which are important aspects of the response to the outbreak, such as those pertaining to support for small businesses and severely stressed sectors of the U.S. economy and childcare.

The understanding and trajectory of the COVID-19 outbreak is changing rapidly, as is the response by Congress and the current administration. Some of the provisions in the CARES Act have already been enhanced by regulatory actions, such as telehealth. Others may be modified by a fourth legislative initiative to address COVID-19, which is now under discussion. Given that, it is important to keep in mind that additional changes may be forthcoming.

The CARES Act is divided into two main parts: Division A, which contains authorizing language for several programs and mandatory spending provisions, and Division B, which contains emergency, discretionary appropriations.

Among the areas addressed under Division A are (in order of appearance in the legislation):

• Provisions to address issues related to drug, device, equipment, and supply shortages/stockpiles.
• Amendments to the Food, Drug, and Cosmetic Act to expedite approval, review, and inspections of drugs and devices in limited circumstances and institute new user fees.
• An amendment to the Families First Coronavirus Response Act to clarify that tests for the detection of SARS–CoV–2 or the diagnosis of the virus that causes COVID–19 are to be covered without cost-sharing by private insurance and Medicare even if that test has not yet received FDA emergency use authorization and an amendment clarifying that Medicaid must cover such tests regardless of whether they are authorized for emergency use by the FDA. Also provides consumer protections around balance billing for these tests.
• Provisions to expand coverage of and offer grants to support broader use of telehealth services including in Medicare, private insurance, and through other federally funded providers (e.g., community health centers).
• Reauthorization of multiple programs including programs to strengthen rural community health, the Healthy Start Program, and Temporary Assistance for Needy Families (TANF).
• Provisions to address potential workforce issues, increasing flexibility for certain federal employee deployments, increasing training opportunities, and adding reporting requirements on workforce issues.
• Several changes related to the Medicare program, including: eliminates certain Medicare requirements related to face-to-face encounters, delays certain scheduled payment reductions in the Medicare program, increases certain Medicare payments for the treatment of patients with COVID-19, permits 90-day supply of prescription drugs during the COVID-19 emergency, and requires coverage of any COVID-19 vaccine without cost-sharing.

Division B includes appropriations for several programs and initiatives, including (in order of appearance in the legislation):

• More than $25 billion for domestic food assistance programs, including the school breakfast and lunch programs, the supplemental nutrition assistance program (SNAP), and the emergency food assistance program.
• $1 billion for Defense Production Act purchases of personal protective equipment and medical equipment, such as ventilators.
• $4.9 billion for the Department of Defense’s Defense Health Program, including $415 million for research and development efforts related to vaccines and antiviral pharmaceuticals and for procurement of diagnostic tests.
• $80 million for a Pandemic Response Accountability Committee to promote transparency and conduct and support oversight of funds.
• $45 billion for the Disaster Relief Fund, which is used by the Federal Emergency Management Agency (FEMA) to fund federal disaster response and assist nonfederal levels of government that have had their capacity to deal with major disasters and emergencies overwhelmed.
• More than $1 billion for the Indian Health Service to prevent, prepare for, and respond to coronavirus.
• $4.3 billion for the Centers for Disease Control and Prevention (CDC) for coronavirus activities.
• Almost $1 billion for the National Institutes of Health (NIH) to support research, including research on coronavirus and developing countermeasures to prevent and treat COVID-19 disease.
• $425 million to the Substance Abuse and Mental Health Services Administration (SAMHSA) to address mental health needs.
• $200 million to the Centers for Medicare and Medicaid Services (CMS) for its coronavirus efforts, of which not less than half must be spent on nursing home inspections with priority given to those in localities with community transmission of COVID-19.
• More than $127 billion for the Public Health and Social Services Emergency Fund at the Department of Health and Human Services (HHS), including, among other things, $100 billion to reimburse hospitals and other health care entities responding to coronavirus for health care-related expenses or lost revenues attributable to coronavirus. It also includes $275 million for Health Resources and Services Administration (HRSA) coronavirus-related activities through certain programs, including $90 million for the Ryan White HIV/AIDS Program.
• More than $17 billion for the Veterans Health Administration to support medical care and related services and facilities during the coronavirus response.
• $678 million to the Department of State, including $350 million to address the needs of vulnerable refugee populations abroad.
• $363 million to the U.S. Agency for International Development (USAID) to address needs in countries that are underequipped to respond to the pandemic.

Overall, we identified $242.4 billion provided for health or health-related activities under Division B, though this estimate should be treated as a floor. More than half of this funding is directed to HHS.

During the emergency period, the amendment requires group health plans and issuers to reimburse providers for a test for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19 as follows:

• If the provider participates in the plan network, the plan shall pay the contracted in-network rate
• If the provider is out-of-network, the plan shall either negotiate a price with the provider, or the plan shall reimburse the provider in an amount equal to the cash price that the provider lists on a public internet website

Geriatrics Workforce Enhancement Program: Directs the Secretary to award grants, contracts, or cooperative agreements to a variety of entities including, health professions schools, schools of nursing, nursing centers, academic health centers, State or local governments, and other appropriate public or private nonprofit entities to establish or operate Geriatrics Workforce Enhancement Programs that meet the following requirements:

• Award supports the training of health professionals in geriatrics, including traineeships or fellowships.
• Activities conducted include clinical training on providing integrated geriatrics and primary care; interprofessional training to practitioners from multiple disciplines including training on the provision of care to older adults; establishing or maintaining training-related community-based programs for older adults and caregivers to improve health outcomes for older adults; providing education on Alzheimer’s disease and related dementias.
• Grant length does not exceed 5 years.

When awarding the grants, Secretary should prioritize certain applicants, such as those with programs or activities that are expected to substantially benefit rural or medically underserved populations of older adults, and give special consideration to those that provide services in areas with a shortage of geriatric workforce professionals.

Geriatrics Academic Career Awards: Directs the Secretary to establish a program to provide geriatric academic career awards to a variety of entities including, health professions schools, schools of nursing, nursing centers, academic health centers, State or local governments, and other appropriate public or private nonprofit entities applying on behalf of eligible individuals to promote the career development of academic geriatricians or other academic geriatrics health professionals.

• The amount of an award shall be at least $75,000 for fiscal year 2021, increasing by CPI for future years.
• The Secretary should not make awards longer than a period of 5 years.

• $200 per day and $2,000 in the aggregate for each employee, when the employee is taking leave to provide caregiving for an individual impacted by COVID-19.

For inpatient services furnished at a long-term care hospital (LTCH) during the emergency period:

• Waives the rule that limits payments for all hospital discharges to the site neutral payment rate if a hospital fails to meet the applicable LTCH discharge threshold of 50%
• Waives site-neutral IPPS payment rate for a discharge at a LTCH, if the admission occurs during the public health emergency and is in response to the public health emergency

• For areas other than rural or non-contiguous areas, Medicare payment rates for durable medical equipment will be based on the fee schedule amount for the area that is equal to 75% of the adjusted payment amount and 25% of the unadjusted fee schedule amount through the duration of the public health emergency. (Current law is based on the fee schedule amount for the area that is equal to 100% of the adjusted payment amount).

Upon the request of the hospital, the Secretary of HHS may:

• Make accelerated payments to eligible hospitals on a periodic or lump sum basis
• Increase the amount of payment that would otherwise be made to hospitals under the program up to 100% (or, in the case of critical access hospitals, up to 125%)
• Extend the period that accelerated payments cover so that it covers up to a 6-month period.

2) Each person that submits an OTC monograph request shall be subject to a fee:

A) For a Tier 1 OTC monograph order request: $500,000, adjusted for inflation

Of the funds provided:

• $3 billion is reserved for making payments to DC and territories (amount divided by each jurisdiction’s share of the total combined population of DC and the 5 territories).
• $8 billion reserved for making payments to tribal governments.
• $139 billion for making payments to the 50 states. States each receive a minimum payment of $1.25 billion. Remaining $76.5 billion allocated proportionately based on a state’s share of the total U.S. population (minus population of DC and territories).
• Local governments (for jurisdiction with population > 500,000) can apply for direct payment; amount comes out of that state’s allocation.

Of the funds provided:

• $15,510,000,000 shall be placed in a contingency reserve to be allocated as the Secretary of Agriculture deems necessary to support participation should cost or participation exceed budget estimates to prevent, prepare for, and respond to coronavirus.
• $100,000,000 for the food distribution program on Indian reservations program to prevent, prepare for, and respond to coronavirus, of which $50,000,000 for facility improvements and equipment upgrades and $50,000,000 for costs relating to additional food purchases.
• $200,000,000 for the Secretary of Agriculture to provide grants to the Commonwealth of the Northern Mariana Islands, Puerto Rico, and American Samoa for nutrition assistance to prevent, prepare for, and respond to coronavirus, domestically or internationally.

• mitigate major risks that cut across program and agency boundaries.
• “Coronavirus response” here means the federal government’s response to the nationwide public health emergency declared by the HHS Secretary, retroactive to Jan. 27, 2020, as a result of confirmed cases of the novel coronavirus – COVID-19 – in the U.S.

Outlines the members of the Committee and the selection of the Chairperson.

States there shall be an Executive Director and Deputy Executive Director of the Committee who shall be appointed by the Chairperson not later than 30 days and the Deputy Executive Director not later than 90 days after the date of enactment of this Act, in consultation with certain congressional leaders, and outlines their experience and duties.

Outlines the Committee’s functions and requires it to submit to the President and Congress management alerts on potential mismanagement, risk, and funding problems that require immediate attention, as well as other reports and periodic updates on its work to Congress as it considers appropriate and a biannual report to the President and Congress. Also describes the public availability of these reports and allowable redaction of them.

Requires the Committee to make recommendations to agencies on related measures and for the agency to respond with a report.

States the Committee may conduct its own independent investigations, audits, and reviews relating to covered funds or the coronavirus response and have certain authorities provided under the Inspector General Act of 1978, issue subpoenas to compel the testimony of persons who are not federal officers or employees, and enforce such subpoenas in the event of a refusal to obey. The Committee may hold public hearings, and Committee personnel may conduct necessary inquiries.

Not later than 30 days after the date of enactment of this Act, the Committee shall establish and maintain a user-friendly, public-facing website. The website shall include a plan from each federal agency for using covered funds.

Authorizes to be appropriated such sums as necessary to carry out the duties and functions of the Committee.

Of the funds provided:

• $25,000,000 for major disasters declared pursuant to the Robert T. Stafford Disaster Relief and Emergency Assistance Act.
• $15,000,000 for all purposes authorized under the Stafford Act and may be used in addition to amounts designated by the Congress as being for disaster relief.
• $3,000,000 for oversight of activities supported by these funds.

Of the funds provided:

• Up to $65,000,000 for electronic health record stabilization and support, including for planning and tribal consultation.
• Not less than $450,000,000 distributed through IHS directly operated programs and to tribes and tribal organizations and through contracts or grants with urban Indian organizations.
• Amounts not allocated above to be allocated at the discretion of the IHS Director.
• Up to $125,000,000 may be transferred to and merged with the ‘‘Indian Health Service, Indian Health Facilities’’ appropriation at the discretion of the Director for the purposes specified in this Act.

Of the funds provided:

• $7,500,000 for necessary expenses of the Geospatial Research, Analysis and Services Program to support spatial analysis and Geographic Information System mapping of infectious disease hot spots, including cruise ships.
• $5,000,000 for necessary expenses for awards to Pediatric Environmental Health Specialty Units and state health departments to provide guidance and outreach on safe practices for disinfection for home, school, and daycare facilities.

Of the funds provided:

• Not less than $1,500,000,000 for grants to or cooperative agreements with states, localities, territories, tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes, including to carry out surveillance, epidemiology, laboratory capacity, infection control, mitigation, communications, and other preparedness and response activities.
  • Every grantee that received a Public Health Emergency Preparedness grant for FY 2019 shall receive not less than 100 percent of that grant level from these funds.
  • Of which, not less than $125,000,000 shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health service providers to tribes.
  • CDC shall report to the House and Senate Committees on Appropriations on the development of a public health surveillance and data collection system for coronavirus within 30 days of enactment of this Act.

  Of the funds provided:

  • Not less than $156,000,000 for the study of, construction of, demolition of, renovation of, and acquisition of equipment for, vaccine and infectious diseases research facilities of or used by NIH, including the acquisition of real property.

  Of the funds provided:

  • Not less than $250,000,000 for the Certified Community Behavioral Health Clinic Expansion Grant program.
  • Not less than $50,000,000 for suicide prevention programs.
  • Not less than $100,000,000 for noncompetitive grants, contracts or cooperative agreements to public entities to enable such entities to address emergency substance abuse or mental health needs in local communities.
  • Not less than $15,000,000 shall be allocated to tribes, tribal organizations, urban Indian health organizations, or health or behavioral health service providers to tribes.

  Of the funds provided:

  • Not less than $100,000,000 for necessary expenses of the survey and certification program, prioritizing nursing home facilities in localities with community transmission of coronavirus.

  Of the funds provided:

  • $820,000,000 for activities authorized under the Older Americans Act of 1965, including $200,000,000 for certain supportive services, $480,000,000 for certain nutrition services, $20,000,000 for certain nutrition services, $100,000,000 for support services for family caregivers, and $20,000,000 for elder rights protection activities.
  • $50,000,000 for certain aging and disability resource centers to prevent, prepare for, and respond to coronavirus.
  • $85,000,000 for centers for independent living that have received certain grants.

  Of the funds provided:

  • Funds may be used to develop and demonstrate innovations and enhancements to manufacturing platforms to support above capabilities.
  • The HHS Secretary shall purchase vaccines developed using these funds to respond to an outbreak or pandemic related to coronavirus in quantities determined by the Secretary to be adequate to address the public health need.
  • Products purchased by the federal government with these funds, including vaccines, therapeutics, and diagnostics, shall be purchased in accordance with Federal Acquisition Regulation guidance on fair and reasonable pricing.
  • The Secretary may take such measures authorized under current law to ensure that vaccines, therapeutics, and diagnostics developed from these funds will be affordable in the commercial market and shall not take actions that delay the development of such products.
  • Products purchased with these funds may, at the discretion of the HHS Secretary, be deposited in the Strategic National Stockpile.
  • Not more than $16,000,000,000 of these funds is for the Strategic National Stockpile.
  • Not less than $250,000,000 for grants to or cooperative agreements with entities that are either grantees or sub-grantees of the Hospital Preparedness Program or that meet such other criteria as the HHS Secretary may prescribe.
  • Not less than $3,500,000,000 to the Biomedical Advanced Research and Development Authority (BARDA) for necessary expenses of manufacturing, production, and purchase, at the discretion of the HHS Secretary, of vaccines, therapeutics, diagnostics, and small molecule active pharmaceutical ingredients, including the development, translation, and demonstration at scale of innovations in manufacturing platforms.
    • These funds may be used for the construction or renovation of U.S.-based next generation manufacturing facilities, other than facilities owned by the United States Government.
    • These funds may be used to reimburse the Department of Veterans Affairs for expenses incurred by the Veterans Health Administration.
    • Not more than $289,000,000 may be transferred as necessary to other federal agencies for necessary expenses related to medical care that are incurred to prevent, prepare for, and respond to coronavirus for persons eligible for treatment pursuant to section 322 of the Public Health Service Act (persons detained in accordance with quarantine laws, or, at the request of the Immigration and Naturalization Service).
    • This funding may be used for grants for the construction, alteration, or renovation of non-federally owned facilities to improve preparedness and response capability at the state and local level and for the production of vaccines, therapeutics, and diagnostics where the HHS Secretary determines that such a contract is necessary to secure sufficient amounts of such supplies.

    Of the funds provided:

    • $90,000,000 to be transferred to the Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program.
      • Funding to be provided through modifications or supplements to existing contracts, grants, and cooperative agreements under Program parts A, B, C, and D, and to AIDS Education and Training Centers by a methodology determined by the Secretary. Traditional requirements related to spending share dedicated to core medical services in Parts A, B, and C do not apply.
      • These funds may not be used to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.
      • Recipients of payments shall submit reports and maintain documentation as the Secretary of Health and Human Services determines are needed to ensure compliance with conditions imposed for such payments.
      • “Eligible health care providers’’ here means public entities, Medicare or Medicaid enrolled suppliers and providers, and such for-profit entities and not-for-profit entities not otherwise described in this proviso as the Secretary may specify, within the United States (including territories), that provide diagnoses, testing, or care for individuals with possible or actual cases of COVID–19.
      • The Secretary of Health and Human Services shall, on a rolling basis, review applications and make payments for this portion of the Act.
      • This funding shall be available for building or construction of temporary structures, leasing of properties, medical supplies and equipment including personal protective equipment and testing supplies, increased workforce and trainings, emergency operation centers, retrofitting facilities, and surge capacity.
      • “Payment” here means a pre-payment, prospective payment, or retrospective payment, as determined appropriate by the Secretary of Health and Human Services.
      • Payments shall be made in consideration of the most efficient payment systems practicable to provide emergency payment.
      • To be eligible for a payment under this funding, an eligible health care provider shall submit to the Secretary of Health and Human Services an application that includes a statement justifying the need of the provider for the payment and the eligible health care provider shall have a valid tax identification number.
      • Not later than 3 years after final payments are made from this funding, the Office of the HHS Inspector General shall transmit a final report on audit findings with respect to this program to the House and Senate Committees on Appropriation; nothing in this section limits the authority of the Inspector General or the Comptroller General to conduct audits of interim payments at an earlier date.
      • Not later than 60 days after the date of enactment of this Act, the Secretary of Health and Human Services shall provide a report to the House and Senate Committees on Appropriations on obligation of funds, including obligations to such eligible health care providers summarized by state of the payment receipt; such reports shall be updated and submitted every 60 days until funds are expended.
      • Section 18113. Up to $4,000,000 to be transferred to, and merged with, funds made available under the heading “Office of the Secretary, Office of the Inspector General” for oversight of activities supported with funds appropriated to the HHS Department to prevent, prepare for, and respond to coronavirus, domestically or internationally.

      Of the funds provided:

      • Not less than $50,000,000 to be allocated pursuant to the formula in statute, using data from FY 2020.
      • Up to $10,000,000 to provide an additional, one-time award to current formula funded grantees administering contracts for permanent supportive housing.
        • Awards shall be made proportionally to their existing grants, do not have to be spent on permanent supportive housing, and can assist with housing payment assistance for rent, mortgage, or utilities payments, which may be provided for a period of up to 24 months.

        Of the funds provided:

        • Funding may be used for training on infectious disease prevention and mitigation and to provide hazard pay, including for time worked prior to the date of enactment of this Act, for staff working directly to prevent, prepare for, and respond to coronavirus among persons who are homeless or at risk of homelessness.
        • That up to 1 percent of this funding may be used to make new awards or increase prior awards made to existing technical assistance providers with experience in providing health care services to homeless populations, without competition, to provide an immediate increase in capacity building and technical assistance available to recipients of amounts for the Emergency Solutions Grants program.
        • None of these funds may be used to require people experiencing homelessness to receive treatment or perform any other prerequisite activities as a condition for receiving shelter, housing, or other services.

        Endnotes

        1. NIH, “About the NIH Common Fund,” webpage, https://commonfund.nih.gov/about, accessed March 27, 2020. ← Return to text