The Biden Administration renewed the COVID-19 public health emergency (PHE) for the final time in February and announced that the PHE declaration will expire May 11. The end of the PHE means that many temporary policies initiated in response to the pandemic will cease or be phased out. Here are five payment and practice-related changes to start preparing for in your practice.
- COVID-19 testing and treatment coverage will change.Over-the-counter COVID-19 tests will no longer be free for many patients. Those with traditional Medicare will no longer receive free over-the-counter or at-home tests, and coverage for patients with Medicare Advantage or private insurance will vary based on their plan.
Tests a physician or other health care professional orders and administers will still be covered by insurance but may not be free for the patient. Traditional Medicare will continue to cover the test itself at no cost to patients but may apply cost-sharing to the associated office visit. Practices may want to inform patients of this beforehand. For patients with Medicare Advantage or private insurance, cost-sharing for both the test and the office visit will depend on the individual plan. Patients on Medicaid can continue to receive free at-home tests as well as tests ordered and administered by a physician or other health care professional through September 2024.
Pharmaceutical COVID-19 treatments purchased by the federal government will continue to be available without cost-sharing, regardless of the patient’s insurance, for a short time after the PHE. The Biden Administration has indicated that it intends to transfer procurement to the traditional marketplace in the late summer or early fall of 2023. At that point, coverage and cost-sharing may shift. For patients with traditional Medicare, treatments will remain covered but may be subject to cost-sharing. This includes oral antivirals such as Paxlovid, which will be covered under Medicare Part D. Private plan coverage and cost-sharing policies will vary. Patients without insurance coverage will pay the full cost for treatments, but safety net clinics may be able to offer treatments on a sliding scale based on the uninsured patient’s income.
- COVID-19 vaccines and boosters will continue to be free, but only while the federal stockpile lasts.Once the federal supply is exhausted, practices that want to keep offering COVID-19 vaccines and boosters will need to purchase their own supply from the traditional marketplace. But the majority of patients with public or private insurance will still be able to receive the vaccines and boosters at no cost to them. After the government-purchased supply runs out, children without insurance will be able to receive the vaccine for free through the Vaccines for Children Program. There may also be a limited supply of free vaccines available for uninsured adults through the Section 317 Immunization Program. Otherwise, patients without insurance will pay the full cost but may be able to receive the vaccine for a sliding scale fee from a safety net clinic.
- Medicaid redeterminations will restart.Continuous Medicaid enrollment will end March 31, 2023, and states will be required to restart Medicaid and CHIP eligibility reviews. Patients who no longer qualify for Medicaid will need to transition to other coverage, such as through the Healthcare.gov marketplace. Patients who do not complete the renewal form will lose their coverage, even if they are still eligible. Additional information and resources are available on the Medicaid website, including a communication toolkit you can give patients to inform them of the steps they need to take and a timeline of when states will start unwinding renewals. The AAFP has developed an informational flyer that highlights what family physicians can do to prepare, such as remind patients to update their contact information with their Medicaid provider, check their mail for renewal notices, and complete paperwork promptly.
- Telehealth will continue to be available after the PHE.The Consolidated Appropriations Act (CAA) of 2023 extended Medicare’s coverage of telehealth for two years. Medicare patients can receive telehealth services at home and can use either audio-video technology or audio-only technology. While coverage itself is extended, there may be shifts in the types of services covered as well as the billing and coding requirements. The Centers for Medicare & Medicaid Services (CMS) plans to release more information on this soon. You can find a list of currently covered Medicare telehealth services on the Medicare Telehealth webpage. The CAA only applies to Medicare patients. Some private payers have already shifted to permanent telehealth policies.
The Drug Enforcement Administration is still developing regulations regarding prescribing controlled substances via telehealth, including buprenorphine for opioid use disorder.
The expanded evaluation and management codes Medicare allowed to be provided without supervision under the primary care exception will end May 11.
- HIPAA enforcement will resume.When the PHE ends, practices will need to transition to a HIPAA-compliant telehealth platform if they’re not already using one. During the PHE, the Office for Civil Rights (OCR) has exercised enforcement discretion and has not imposed penalties if a practice provided telehealth services with a non-public facing communications platform (e.g., Apple’s FaceTime). But when the PHE ends, the OCR will resume penalties for breaches of electronic patient health information in violation of the HIPAA Security Rule. All telehealth services, including audio-only services, will need to be provided using a HIPAA-compliant platform. The OCR intends to release a notice to a public when it is no longer exercising its enforcement discretion. Additional information is available on the HHS HIPAA and COVID-19 webpage.
These are just a few of the top items for practices to be aware of as we move toward the end of the PHE. More tips are available from AAFP News. CMS and HHS have released initial guidance and will continue to issue additional information on a rolling basis:
- Fact Sheet: COVID-19 Public Health Emergency Transition Roadmap,
- Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency,
- Coronavirus Waivers and Flexibilities,
- Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19,
The Kaiser Family Foundation has also produced several helpful resources:
- What Happens When COVID-19 Emergency Declarations End? Implications for Coverage, Costs, and Access,
- The End of the COVID-19 Public Health Emergency: Details on Health Coverage and Access,
- Commercialization of COVID-19 Vaccines, Treatments, and Tests: Implications for Access and Coverage.
— Erin Solis, AAFP Manager of Practice and Payment