What providers can expect when waivers expire at end of the PHE

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The Centers for Medicare and Medicaid Services has released guidance for beneficiaries and providers on what to expect when the Public Health Emergency ends on Thursday, May 11.

Under the PHE, healthcare providers received maximum flexibility to streamline delivery and allow access to care, CMS said. While many of these waivers are coming to an end with the expiration of the PHE, the $1.7 trillion Consolidated Appropriations Act President Biden signed into law in December 2022 includes an extension of telehealth waivers and the Acute Hospital Care at Home individual waiver.

ACUTE HOSPITAL CARE AT HOME

The Acute Hospital Care at Home initiative allowed hospitals to expand their capacity to provide inpatient care in an individual's home. This flexibility has been extended through Dec. 31, 2024. 

Many hospitals and individuals participated in this initiative, CMS said, as indicated by the broad geographic distribution of hospitals participating, ranging in size and services from small rural settings to large academic settings. 

TELEHEALTH

During the PHE, waivers allowed individuals with Medicare to have access to telehealth services from their homes, without the geographic or location limits that applied prior to the PHE. It allowed providers to remotely provide care in place of an in-person office visit.

The Consolidated Appropriations Act extended many telehealth flexibilities through Dec. 31, 2024.

For people with Medicare, these include: Access to telehealth services in any geographic area in the United States, rather than only those in rural areas; access from home rather than traveling to a healthcare facility; and allowing for certain telehealth visits to be delivered by audio only (such as a telephone) if someone is unable to use both audio and video, such as on a smartphone or computer.

Medicare Advantage plans may offer additional telehealth benefits, CMS said. After Dec. 31, 2024, when these flexibilities expire, some Accountable Care Organizations may also offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live. 

For Medicaid and CHIP beneficiaries, telehealth flexibilities are not tied to the end of the PHE and have been offered by many state Medicaid programs long before the COVID-19 pandemic, CMS said. Coverage will ultimately vary by state, with the agency encouraging states to continue telehealth coverage.

For individuals with private insurance, coverage for telehealth and other remote care services will vary by plan after the end of the PHE. When covered, private insurance may impose cost-sharing, prior authorization or other forms of medical management on telehealth and other remote care services.

WHY THIS MATTERS

"Thanks to the Administration's whole-of-government approach to combating the virus, we are in a better place in our response than we were three years ago, and we can transition away from an emergency phase," CMS said.

COVID-19 VACCINES, TESTING AND TREATMENTS

Medicare

People with Medicare coverage will continue to have access to COVID-19 vaccinations without cost sharing after the end of the PHE.
Additionally, people with traditional Medicare can continue to receive COVID-19 PCR and antigen tests with no cost sharing when the test is ordered by a physician or certain other providers, such as physician assistants and certain registered nurses, and performed by a laboratory. 

People enrolled in Medicare Advantage plans can continue to receive COVID-19 PCR and antigen tests when the test is covered by Medicare, but their cost-sharing may change when the PHE ends. By law, Medicare does not generally cover over-the-counter services and tests. Current access to free over-the-counter COVID-19 tests will end with the end of the PHE. However, some Medicare Advantage plans may continue to provide coverage as a supplemental benefit.

There is no change in Medicare coverage of treatments for those exposed to COVID-19 once the PHE ends, and in cases where cost sharing and deductibles apply now, they will continue to apply. Generally, the end of the COVID-19 PHE does not change access to oral antivirals, such as Paxlovid and Lagevrio.

Medicaid and CHIP

States must provide Medicaid and CHIP coverage without cost sharing for COVID-19 vaccinations, testing and treatments through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 PHE. If the COVID-19 PHE ends on May 11, this coverage requirement will end on Sept. 30, 2024.

After that date, many Medicaid and CHIP enrollees will continue to have coverage for COVID-19 vaccinations, CMS said. After coverage requirements expire, Medicaid and CHIP coverage of COVID-19 treatments and testing may vary by state.

Additionally, 18 states and U.S. territories have opted to provide Medicaid coverage to uninsured individuals for COVID-19 vaccinations, testing and treatment. Under federal law, Medicaid coverage of COVID-19 vaccinations, testing and treatment for this group will end when the PHE ends.

Private Health Insurance

Most forms of private health insurance must continue to cover COVID-19 vaccines furnished by an in-network healthcare provider without cost sharing. People with private health insurance may need to pay part of the cost if an out-of-network provider vaccinates them.

After the expected end of the PHE, mandatory coverage for over-the-counter and laboratory-based COVID-19 PCR and antigen tests will end, though coverage will vary depending on the health plan. If private insurance chooses to cover these items or services, there may be cost sharing, prior authorization or other forms of medical management may be required.

The transition forward from the PHE will not change how treatments are covered, and in cases where cost sharing and deductibles apply now, they will continue to apply.

THE LARGER TREND

Blanket waivers will end at the end of the PHE.

These include: waivers of the requirement for three-day prior inpatient hospitalization for Medicare coverage of a skilled nursing facility stay; waivers of the requirements that Critical Access Hospitals limit the number of inpatient beds to 25 and general limitations on CAH lengths of stay to no longer than 96 hours on average; and waivers to allow acute care patients to be housed in other facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels and dormitories.

These waivers were intended to temporarily expand healthcare capacity when needed and generally cannot be made permanent without a legislative change. 

Medicaid Continuous Enrollment Condition

The continuous enrollment condition for individuals enrolled in Medicaid is no longer linked to the end of the PHE. Under the Families First Coronavirus Response Act, states claiming a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage (FMAP) have been unable to terminate enrollment for most individuals enrolled in Medicaid as of March 18, 2020, as a condition of receiving the temporary FMAP increase.

As part of the Consolidated Appropriations Act, 2023, the continuous enrollment condition will end on March 31, 2023. The temporary FMAP increase will be gradually reduced and phased down beginning April 1, 2023 (and will end on Dec. 31, 2023). For more information, visit Medicaid.gov/unwinding.

Twitter: @SusanJMorse
Email the writer: SMorse@himss.org