Impact of the COVID-19 public health emergency (PHE) expiration on coverage and care delivery

By Zachary Solomon, Creative Director, Mosaic

Background

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

Waiving of out-of-pocket costs for COVID-19 testing, vaccination and treatment
Provisions to support continuous enrollment in Medicaid plans
Increased reimbursement for telehealth services to allow for virtual care
Increased flexibility for hospital systems/HCPs to manage COVID-19 treatment

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

Key dates

January 31, 2020: Start of the PHE
March 13, 2020: Start of the National Emergency
May 11, 2023: End of the PHE and many COVID-19 waivers/flexibilities
September 20, 2024: End of key Medicaid provisions
December 31, 2024: End of select provisions extended by the Consolidated Appropriations Act (CAA) of 2023

Key impacts

Changes in out-of-pocket costs and reimbursement for COVID-19 testing,
prevention, and treatment^3-5,7

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.

Vaccines: Currently, the COVID-19 vaccine supply is provided by the government free of charge. Vaccinations will remain free for patients as long as the government-provided supply lasts. After that, patients covered by commercial insurance, Medicaid or Medicare Part D will continue to receive these vaccines free of charge (with costs covered by the payer) as long as they are provided in-network
At-home tests: Commercial and Medicare patients may be required to pay OOP following the PHE unless their plan opts to cover these at no cost. For Medicaid, these tests will continue to be covered at no cost through September 2024, after which coverage will vary by state
Tests ordered/administered by HCPs: Commercial and Medicare Advantage patients may need to pay OOP for office visits and the test, and plans may restrict access. Traditional Medicare patients will only pay OOP for the office visits, and Medicaid patients will continue to receive free testing through September 2024, after which they may see limits or nominal OOP costs
Treatment: Oral COVID-19 treatments purchased and made available by the federal government will continue to remain free of charge as long as the supply lasts. For treatments not purchased by the federal government, patients with commercial or Medicare coverage may face cost-sharing requirements, whereas patients with Medicaid and Children’s Health Insurance Program (CHIP) will continue be covered with no cost sharing through September 2024. After that date, patients may see utilization restrictions or nominal cost-sharing based on their state of residence

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 Medicaid^3,4,9,10

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 reimbursement^3,4,9

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.

Medicare: During the PHE, the Centers for Medicare & Medicaid Services (CMS) granted increased flexibility for the use of telehealth for Medicare patients. This included expanding access to telehealth beyond rural areas, allowing telehealth to be done from home, allowing audio-only telehealth, and expanding the list of services that could be provided. These flexibilities have been extended through December 2024
Medicaid/CHIP: Flexibilities related to telehealth are not tied to the PHE and will not expire. Coverage will vary by state, with most states planning to make telehealth flexibilities permanent
Commercial: Commercial insurance coverage of telehealth services will continue to vary by plan following the PHE

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 patients^{3,4,8,9,11-13}

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.

Shift of care from the hospital: With hospitals managing increased patient loads, CMS granted flexibility to allow for the shift of care to other settings for patients with traditional Medicare and Medicaid Fee-For-Service (FFS). This included an initiative that allows hospitals to increase the provision of acute care in home settings, which is in effect through December 2024. In addition, CMS relaxed the 3-day hospitalization requirement for Medicare patients to qualify for skilled nursing facilities, which will end following the PHE
Relaxation of requirements for hospitals and HCPs: During the PHE, CMS provided several waivers related to the provision of care in hospitals for patients with traditional Medicare or Medicaid FFS. This included waivers to allow for more time to complete medical records (typically required at discharge)–which expired at the end of the PHE–and changing the requirements for HCPs to allow for virtual supervision instead of requiring a physical presence–which will remain through December 2023
Supporting Medicare patients: Two additional provisions that expire after the PHE include allowing Medicare Advantage patients to receive care from out-of-network providers with no increased cost share and allowing Medicare Part D patients to receive 90-day supplies of covered medications if requested. The provision for out-of-network care will expire 30 days after either the end of the PHE or individual state disaster declarations (whichever comes later). The allowance for 90-day supplies of medications expired at the end of the PHE, after which point access to extended supplies depends on a patient’s plan and the type of medication (eg, generic vs brand)
Waiving quality measure reporting: During the PHE, CMS suppressed quality measure reporting for certain measures impacted by the pandemic, including the 30-Day Pneumonia Readmissions Measure for the Hospital Readmissions Reduction Program and the Hospital 30-Day, All Cause, Risk Standardized Mortality Rate Following Pneumonia (PN) Hospitalization measure for the Hospital Value-Based Purchasing (VBP) Program. These two measures will go back in place in 2024, although COVID-19 patients will be excluded from the readmissions measure

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.

Implications

Payers

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

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.

Providers

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.

Manufacturers

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.

Conclusion

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.

If you have any questions or would like to discuss this topic further, please contact reta.mourad@mosaic-mm.com.

^{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.}

References

¹ Declarations of a public health emergency

² A public health emergency declaration

³What 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