By Zachary Solomon, Creative Director, Mosaic
On January 31, 2020, the US Secretary of Health and Human Services (HHS) first declared COVID-19 a public health emergency (PHE), which allowed for a 90-day period during which the Secretary could take appropriate action to address the public health need.1,2 Since this initial declaration, the PHE has been extended several times, enabling various changes to our healthcare system to help healthcare providers (HCPs) navigate the COVID-19 pandemic.1,3 These include:3-5
The COVID-19 PHE expired on May 11, 2023.4 As a result, many of the regulations and policies that were put into place during the PHE have also expired, resulting in changes to both coverage for patients and the overall delivery of care for providers.3,4
Changes in out-of-pocket costs and reimbursement for COVID-19 testing,
prevention, and treatment3-5,7
During the PHE, patients were able to access tests, vaccines and certain COVID-19 treatments (eg, Paxlovid) without cost-sharing. With the PHE ending, patient out-of-pocket (OOP) costs may vary, with some services remaining free of charge and others requiring cost-sharing based on coverage.
Takeaway: Patients may see OOP requirements for COVID-19 tests and treatments as government supply runs out and payers begin to cover the balance of the cost. Patients with commercial, Medicaid or Medicare Part D coverage will be able to receive vaccines free of charge based on provisions in the Affordable Care Act (ACA) and the Inflation Reduction Act (IRA).*
*The ACA required that non-grandfathered commercial plans and state programs that expanded Medicaid cover all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) with cost sharing. The IRA expanded access to vaccines by removing cost sharing for ACIP-recommended vaccines for Medicare Part D patients and requiring all state Medicaid programs to cover these vaccines.8
Potential impact on health insurance coverage for patients on Medicaid3,4,9,10
To support continuity of care during the PHE, Congress provided additional funding to state Medicaid programs that met several conditions, including providing continuous eligibility. This means states were not conducting redeterminations to see if Medicaid patients were still qualified for coverage, reducing the “churn” of patients disenrolling/re-enrolling. The continuous enrollment requirement is no longer tied to the PHE and expired on March 31, 2023. Most states are planning to process disenrollments over the next year, which may result in between 5 million and 14 million patients losing Medicaid coverage. This may lead to an increase in patients without insurance or who have a gap in coverage.
Takeaway: Patients with Medicaid may be subject to disenrollment over the next 12 months, which can result in gaps in coverage and treatment and potentially impact overall patient care.
Reduction in flexibility for telemedicine reimbursement3,4,9
Access to telehealth services expanded substantially during the COVID-19 pandemic, as more patients sought care virtually to avoid in-person visits. Many payers relaxed their management and increased reimbursement of telehealth in support of this new approach to care.
Takeaway: While telehealth allowances for Medicaid and commercial insurers are expected to largely continue as they are not related to the PHE, Medicare patients may see a decrease in telehealth flexibility in 2025.
Expiration of provisions that granted additional flexibility to hospitals, HCPs, and patients3,4,8,9,11-13
During the PHE, several provisions were put in place to provide flexibility for stakeholders to help navigate disruption to our system. Many of these expired at the end of the PHE, or will do so in the near future.
Takeaway: Many of the allowances that enabled patients to receive care outside of the hospital setting will expire, resulting in a potential shift of patients back to the inpatient setting. In addition, flexibilities for patients and HCPs will expire, with pre–COVID-19 requirements going back into place.
With the ending of the PHE, payers will see a shift of costs related to COVID-19 vaccines and treatments once the government supply runs out. This will increase costs for payers while resulting in increased costs for their members. In addition, the end of Medicaid continuous enrollment may cause increased churn for insurance providers, with patients potentially moving from Medicaid to Exchange plans, or reenrolling in Medicaid. This may result in increased costs for payers, which could in turn lead to increased scrutiny on the financial impact of new drugs coming to market.
Patients may see an increase in payer restrictions and out-of-pocket costs related to COVID-19-related treatment. In addition, those currently enrolled in Medicaid may see a disruption in care as states process disenrollments following the PHE and increased “churn” as patients may shift between Medicaid, Health Insurance Exchange Plans, or periods of time with no insurance. This could further increase patient costs and make access to medication more challenging. In addition, patients who have adapted to using telehealth to receive care may see a shift back towards in-person visits, particularly as Medicare waivers expire.
Healthcare professionals, particularly those who treat Medicaid patients, may face challenges navigating changes in patient coverage, which may disrupt care plans and place additional burden on office staff who may need to submit new prior authorizations to support continued coverage. Hospital-based providers may also see a return to pre–COVID-19 norms as flexibilities for documentation and supervision expire, putting additional requirements (and therefore burden) back in place.
The shift in how care is provided as well as the potential disruption in patient coverage may impact patients’ abilities to start or stay on treatment. Manufacturers can help customers navigate these challenges by ensuring their reimbursement support teams, call center HUBs, and patient liaisons are prepared for these shifts over the next year. Payer marketers may also see increased scrutiny from payers on new product launches due to the increase in costs for payers related to COVID-19. This may make preapproval communications even more important after the PHE expiration in order to help payers as they navigate these increased costs and strive to limit the budgetary impact.
The COVID-19 pandemic brought about substantial changes in how care is delivered in the United States. While some of these changes are due to expire, resulting in disruption for stakeholders as regulations return to pre–COVID-19 norms, other flexibilities are expected to stay in place for the coming year. Stay tuned for additional updates on how regulations in the United States continue to evolve after the PHE.
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Note: Information in this POV has been summarized based on a variety of sources and focuses on select impacts and implications resulting from the end of the PHE. Please refer to the reference section for additional information.
1 Declarations of a public health emergency
2 A public health emergency declaration
3 What happens when COVID-19 emergency declarations end?
4 CMS waivers, flexibilities, and the transition forward
5 The end of the COVID-19 public health emergency
6 Declaring a national emergency concerning the novel coronavirus disease (COVID-19) outbreak
7 Several changes to adult vaccine access enacted through IRA
8 COVID-19 emergency declaration blanket waivers for health care providers
9 Public health emergency to end May 11. American Hospital Association
10 Things to know about the unwinding of the Medicaid continuous enrollment provision
11 Examining Medicare Part D policies for extended supplies of medication
12 Acute hospital care at home: the CMS waiver experience
13 The PHE is ending: what it means for COVID-19 waivers, funding and other flexibilities