What Happens When COVID-19 Emergency Declarations End? Implications for Coverage, Costs, and Access

With greater than two years having handed because the COVID-19 pandemic started in early 2020, questions are being raised about when to finish the general public well being emergency declarations made by the federal authorities early on, with some advocating for his or her extension and others calling for his or her expiration. There are quite a few implications to ending these emergency declarations, every of which gave the federal authorities flexibilities to waive or modify sure necessities in a spread of areas, together with within the Medicare, Medicaid, and CHIP applications, and in non-public medical insurance, in addition to to permit for the authorization of medical countermeasures and to offer legal responsibility immunity to suppliers who administer companies, amongst different issues. As well as, Congress additionally enacted legislation that offered further flexibilities tied to a number of of those emergency declarations, and as such they too are scheduled to run out when (or at a specified time after) the emergency interval(s) expires.

This transient offers an summary of the most important health-related COVID-19 federal emergency declarations which were made, summarizes the flexibilities triggered by every, and identifies the implications for his or her ending, within the following areas:

This isn’t meant to be an exhaustive checklist of all federal coverage and regulatory provisions made in response to COVID-19 emergency declarations. For instance, we don’t cowl all the vary of federal and state emergency authorities exercised below Medicaid Catastrophe Aid State Plan Amendments (SPAs), different Medicaid and CHIP SPAs, and different state-reported administrative actions; Part 1115 waivers; Part 1135 waivers; and 1915 (c) waiver Appendix Okay methods. The Facilities for Medicare & Medicaid Providers maintains a more complete list of coronavirus waivers and flexibilities which were exercised since early 2020; some state actions to answer the emergency might have expiration dates that aren’t tied to the tip of the federal emergency declarations.

Overview of Main Well being-Associated COVID-19 Federal Emergency Declarations

The early days of the COVID-19 pandemic had been marked by a number of emergency declarations made by the federal authorities, below a number of broad authorities, every of which has completely different necessities associated to expiration.

  • A public health emergency (PHE) was initially declared by the Secretary of the Division of Well being and Human Providers (HHS) in late January 2020, pursuant to Part 319 of the Public Health Service Act. A PHE lasts for 90 days and should be renewed to proceed; the PHE for COVID-19 has been renewed a number of occasions, most just lately in January 2022, and is at present scheduled to run out in mid-April 2022. The Biden Administration has stated that it’ll give states a 60 day notice earlier than the PHE expires.
  • A national emergency declaration was issued by former President Donald Trump in March of 2020, pursuant to Part 201 of the National Emergencies Act. A nationwide emergency declaration is in impact except terminated by the President, or by means of a joint decision of Congress, or if the President doesn’t situation a continuation discover yearly. Such a discover was issued by President Trump to proceed the emergency past March 1, 2021 and by President Biden to continue beyond March 1, 2022.
  • A separate emergency declaration pursuant to Part 564 of the Federal Meals, Drug, and Beauty (FD&C) Act was issued by the Secretary of HHS in February 2020. Primarily based on this willpower, on March 27, 2020, the Secretary declared that circumstances existed to justify emergency use authorization (EUA) of medical countermeasures for COVID-19. An EUA is a mechanism to facilitate availability and use of medical countermeasures which can be decided to be secure and efficient however haven’t but been formally authorized. An emergency declaration issued pursuant to Part 564 of the FD&C Act stays in impact till terminated by the HHS Secretary.
  • A declaration below the Public Readiness and Emergency Preparedness (PREP) Act (pursuant to Part 319F-3 of the Public Well being Service Act) was issued by the Secretary of HHS in March 2020. This declaration offers legal responsibility immunity for actions associated to COVID-19 medical countermeasures. Since then, 10 amendments to the declaration have been issued to increase liabilities associated to COVID-19 countermeasures. For a PREP Act emergency willpower, the Secretary should specify an finish date; on this case, it has been set as October 1, 2024.

Key Flexibilities Triggered by Main COVID-19 Federal Emergency Declarations

Description Expiration Implications
Beneficiaries in conventional Medicare and Medicare Benefit pay no cost sharing for COVID-19 at-home testing (as much as eight checks monthly), testing-related companies, and certain treatments. Finish of § 319 PHE Thousands and thousands of individuals have acquired free COVID-19 testing and testing-related companies, sure remedies, and vaccines in the course of the § 319 PHE, however not all of these things will proceed to be free when the PHE ends.

For folks with out insurance coverage, there’ll not be a pathway by means of Medicaid without spending a dime COVID-19 testing, vaccines, or remedy.

Medicare beneficiaries will face price sharing necessities for at-home checks, testing-related companies, and all COVID-19 remedies when the
§ 319 PHE ends. Protection of COVID-19 vaccines will proceed for gratis because of statutory adjustments made by the CARES Act that added protection of COVID-19 vaccines to Medicare Half B. Medical diagnostic testing can also be coated for gratis.

For Medicaid and CHIP enrollees, state Medicaid applications can select to proceed to cowl COVID-19 testing, remedy, and vaccines for many adults after federal protection necessities associated to the § 319 PHE expire.

Privately insured people might incur further out-of-pocket prices for checks and associated companies when the § 319 PHE ends. Individuals with non-public insurance coverage will proceed to have protection of COVID-19 vaccines for gratis from in-network suppliers, because of statutory adjustments made by the CARES Act that prolonged the requirement below non-public insurance coverage for protection of preventive companies for gratis to incorporate COVID-19 vaccines.

Individuals with non-public insurance coverage who obtain COVID-19 vaccines, together with booster doses, from out-of-network suppliers might incur out-of-pocket prices when the § 319 PHE ends.

Enrollees obtain protection of COVID-19 vaccines and vaccine administration with out price sharing. Final day of first calendar quarter starting one yr after finish of § 319 PHE
Enrollees obtain protection of coronavirus testing and COVID-19 remedy companies with out price sharing. States obtain enhanced federal matching funds in the event that they meet the situations described beneath. Final day of calendar quarter by which § 319 PHE ends, besides that remedy companies should be coated for enrollees in different profit plans by means of the final day of the primary calendar quarter starting one yr after finish of § 319 PHE
New eligibility pathway to cowl COVID-19 testing and testing-related, vaccinations, and remedy companies for uninsured people; protection group elected at state possibility with 100% federal matching funds. Finish of § 319 PHE
Group well being plans and particular person medical insurance plans are required to cowl COVID-19 checks and testing-related companies with out price sharing or prior authorization or different medical administration necessities.

Starting January 15, 2022, this requirement applies to over-the-counter (OTC) COVID-19 checks licensed, cleared, or authorized by the FDA. Well being plans should cowl as much as 8 free OTC at-home checks per coated particular person monthly, and no doctor’s order or prescription is required. Plans might restrict reimbursement to at least the precise or negotiated value or $12 per check (whichever is decrease). Plans can arrange a community of suppliers, akin to pharmacies or retailers, to offer OTC checks without spending a dime quite than having sufferers to pay up entrance and submit claims for reimbursement, however the protection requirement applies whether or not or not shoppers get checks from taking part suppliers.

Finish of § 319 PHE
For checks and associated companies furnished by out of community suppliers, group well being plans and particular person medical insurance (together with grandfathered plans) shall reimburse the supplier both at a negotiated price or, if no price is negotiated, at an quantity equal to the money value posted on-line by the supplier. Finish of § 319 PHE
Plans and issuers should cowl COVID-19 vaccines with out price sharing when offered by out-of-network suppliers and should reimburse out-of-network suppliers an inexpensive quantity for vaccine administration; federal rules specify the Medicare reimbursement price for vaccine administration is an inexpensive quantity. Finish of § 319 PHE

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Description Expiration Implications
States obtain a 6.2 share level increase of their common federal matching price (FMAP) in the event that they meet the next conditions:

  • Cowl coronavirus testing and COVID-19 remedy companies, together with vaccines, specialised tools, and therapies, with out cost-sharing
  • Steady enrollment: states usually should present steady eligibility for people enrolled in Medicaid on or after 3/18/20; states might not switch an enrollee to a different protection group that gives a extra restrictive profit bundle
  • Upkeep of eligibility requirements: states should not implement extra restrictive eligibility requirements, methodologies or procedures than these in impact on 1/1/20
  • No will increase to premiums: states should not undertake increased premiums than these in impact on 1/1/20
  • Upkeep of political subdivisions’ contributions to non-federal share of Medicaid prices: states should not enhance political subdivisions’ contributions to the non-federal share of Medicaid prices past what was required on 3/1/20
For steady enrollment: final day of month by which § 319 PHE ends

For different provisions: final day of calendar quarter by which § 319 PHE ends

The continual enrollment  requirement contributed to Medicaid enrollment growth of 20.5% between February 2020 and November 2021.

Thousands and thousands of individuals might lose Medicaid protection and/or probably face increased prices for Medicaid protection when the § 319 PHE ends. In 20 states in a position to report, it’s estimated that about 13% of Medicaid enrollees shall be disenrolled when the continual enrollment requirement ends. CMS guidance emphasizes selling continuity of protection and avoiding inappropriate protection terminations when the continual protection requirement ends.

State spending on Medicaid is prone to enhance when the improved FMAP ends

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Description Expiration Implications
Among the many main adjustments to Medicare protection of telehealth in the course of the PHE:

  • Medicare beneficiaries in any geographic space can obtain telehealth companies, quite than beneficiaries residing in rural areas solely
  • Beneficiaries can stay of their properties for telehealth visits reimbursed by Medicare, quite than needing to journey to a well being care facility
  • Telehealth visits could be delivered through smartphone in lieu of apparatus with each audio and video functionality
  • An expanded list of Medicare-covered companies could be offered through telehealth
The Consolidated Appropriations Act of 2022 prolonged these flexibilities for 151 days starting on the primary day after the tip of the § 319 PHE Expanded protection of telehealth in the course of the PHE has enabled tens of millions of individuals to entry well being care companies that they could in any other case have foregone in the course of the pandemic.

For instance, over 28 million Medicare beneficiaries used telehealth in the course of the first yr of the pandemic, and telehealth accounted for 12% of all companies utilized by beneficiaries in the course of the first yr of the pandemic.

Absent everlasting adjustments to Medicare protection, most Medicare beneficiaries will lose entry to protection of almost all telehealth companies on the 152nd day after expiration of the § 319 PHE, except they reside in rural areas or enroll in Medicare Benefit.

Primarily based on adjustments within the Consolidated Appropriations Act of 2021, Medicare has completely eliminated geographic restrictions for psychological well being and substance use companies and completely permits beneficiaries to obtain these companies at dwelling. Medicare additionally now completely covers audio-only visits for psychological well being and substance use companies.

As of summer 2021, post-pandemic Medicaid telehealth insurance policies had been into account in most states, with many states planning to keep up all or some expanded telehealth insurance policies that had been adopted in the course of the COVID-19 pandemic. In states that select to not proceed these insurance policies, nevertheless, enrollees might lose entry to telehealth companies.

Federally certified well being facilities and rural well being clinics can present telehealth companies to Medicare beneficiaries (i.e., could be distant web site suppliers), quite than restricted to being an originating web site supplier for telehealth (i.e., the place the beneficiary is situated) The Consolidated Appropriations Act of 2022 prolonged this flexibility for 151 days starting on the primary day after the tip of the § 319 PHE
All 50 states and DC expanded protection and/or entry to telehealth companies in Medicaid. States have broad authority to cowl telehealth in Medicaid and CHIP with out federal approval, together with flexibilities for allowable populations, companies and fee charges, suppliers, expertise, and managed care necessities. Varied; could also be tied to federal and/or state public well being emergencies. Many states have made some Medicaid telehealth flexibilities everlasting.
All states and D.C. briefly waived some points of state licensure necessities, in order that suppliers with equal licenses in different states might follow through telehealth. Various; in some states; these waivers are nonetheless energetic and tied to the tip of § 319 PHE, in others they’ve expired. Some states have made allowances for long-term or everlasting interstate telemedicine.
HHS waived potential penalties for HIPAA violations in opposition to well being care suppliers that serve sufferers in good religion by means of on a regular basis communications applied sciences in the course of the COVID-19 nationwide public well being emergency, which permits for extensively accessible companies like FaceTime or Skype for use for telemedicine functions, even when the service shouldn’t be associated to COVID-19. Finish of § 319 PHE
DEA-registered suppliers can use telemedicine to situation prescriptions for managed substances to sufferers with out an in-person analysis, in the event that they meet certain conditions. Finish of § 319 PHE, except DEA specifies an earlier date

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Description Expiration Implications
Catastrophe-Aid State Plan Amendments (SPAs) permit HHS to approve state requests to make short-term adjustments to handle eligibility, enrollment, premiums, cost-sharing, advantages, funds, and different insurance policies differing from their authorized state plan in the course of the COVID-19 emergency. States might not make adjustments that prohibit or restrict fee, companies, or eligibility or in any other case burden beneficiaries and suppliers. Permitted Catastrophe-Aid SPAs as of July 1, 2021 are listed in KFF’s Medicaid Emergency Authority Tracker Finish of § 319 PHE or earlier date chosen by state All 50 states and DC have used these Medicaid emergency authorities to handle pandemic-related challenges for suppliers and enrollees, akin to by:

Though these authorities expire at completely different occasions associated to the PHE, states can select to proceed some changes even after the emergency ends.

Absent state actions to take action would lower beneficiary entry to companies and help for suppliers.

COVID-19 Part 1115 demonstration waivers permit HHS to approve state requests to function Medicaid applications with out regard to particular statutory or regulatory provisions to furnish medical help in a fashion supposed to guard, to the best extent potential, the well being, security, and welfare of people and suppliers who could also be affected by COVID-19. Permitted COVID-19 Part 1115 waivers as of July 1, 2021 are listed in KFF’s Medicaid Emergency Authority Tracker 60 days after § 319 PHE ends or earlier date authorized by CMS
Part 1135 waivers permit HHS to approve state requests to waive or modify sure Medicare, Medicaid, and CHIP necessities to make sure that ample well being care objects and companies can be found to fulfill the wants of enrollees served by these applications in affected areas. Permitted Part 1135 waivers for Medicaid as of July 1, 2021 are listed in KFF’s Medicaid Emergency Authority Tracker No later than the tip of
§ 319 PHE
Part 1915(c) Appendix Okay waivers permit HHS to approve state requests to amend Part 1915(c) or Part 1115 HCBS waivers to answer an emergency. For instance, states can modify or develop HCBS eligibility or companies, modify or droop service planning and supply necessities, and undertake insurance policies to help suppliers. Permitted Part 1915(c) Appendix Okay waivers as of July 1, 2021 are listed in KFF’s Medicaid Emergency Authority Tracker No later than six months after § 319 PHE ends

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Description Expiration Implications
For the remedy of sufferers recognized with COVID-19, hospitals obtain a 20% enhance within the Medicare fee price by means of the hospital inpatient potential fee system. Finish of § 319 PHE Hospitals will not obtain the 20% fee enhance for discharges of sufferers recognized with COVID-19 when the § 319 PHE expires.

Between January 2020 and November 2021, Medicare fee for the roughly 1 million beneficiaries in conventional Medicare hospitalized for COVID-19 hospitalizations over this time interval totaled $23.4 billion, or just over $24,000 per patient

The three-day prior hospitalization requirement is waived for expert nursing facility (SNF) stays for these Medicare beneficiaries who have to be transferred due to the impact of a catastrophe or emergency. Beneficiaries who might have just lately exhausted their SNF advantages can have renewed SNF protection with out first having to begin a brand new profit interval. No later than the tip of
§ 319 PHE
Medicare beneficiaries will once more must fulfill the 3-day prior hospitalization requirement in an effort to have Medicare protection of SNF stays when the
§ 319 PHE expires.
Medicare Benefit plans are required to cowl companies at out-of-network amenities that take part in Medicare, and cost enrollees who’re affected by the emergency and who obtain care at out-of-network amenities not more than they’d face if they’d acquired care at an in-network facility. Per CMS’s recently proposed revision to Medicare regulations, ends 30 days after the most recent relevant finish date of § 319 PHE, § 564 nationwide emergency, or state catastrophe declaration (when a number of declarations apply to the identical geographic space), i.e., ends when all sources that declared a catastrophe or emergency that embody the service space have declared an finish; or there isn’t a longer a disruption to entry of well being care Medicare Benefit enrollees who’ve been shielded from increased out-of-pocket prices related to companies acquired from out-of-network suppliers might face increased prices when the
§ 319 PHE expires.
Medicare Half D plans (each stand-alone drug plans and Medicare Benefit drug plans) should present as much as a 90-day (3 month) provide of coated Half D medicine to enrollees who request it. Finish of § 319 PHE Half D plans will not be required to situation prolonged provides for all Half D medicine they cowl after the § 319 PHE ends. Underneath policies in place in 2020 previous to the pandemic, most Half D enrollees had been in plans that coated prolonged provides of generic medicine, however solely a small share had entry to prolonged provides of specialty medicine.
Part 1135 waivers permit the Secretary of the Division of Well being and Human Providers to waive sure program necessities and situations of participation to make sure that Medicare beneficiaries can get hold of entry to advantages and companies.

CMS has issued many blanket waivers and flexibilities for well being care suppliers which can be in impact in the course of the COVID-19 PHE to forestall gaps in entry to look after beneficiaries impacted by the emergency.

No later than the tip of
§ 319 PHE
Regular guidelines and rules for Medicare program necessities and situations of participation will apply to all relevant suppliers and suppliers as soon as the PHE ends.

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Description Expiration Implications
Extension of election and spot deadlines for COBRA, different group well being plan provisions: group well being plans topic to ERISA or the Inner Income Code should disregard “the Outbreak Interval” (outlined because the interval starting March 1, 2020 and ending 60 days after the tip of the COVID-19 Nationwide Emergency, or such different finish date introduced) in figuring out the next intervals and dates:

  • the 60-day election interval for COBRA continuation protection
  • the date for making COBRA premium funds
  • the deadline for employers to offer people with discover of their COBRA continuation rights
  • the 30-day (or 60-day in some instances) Particular Election Interval (SEP) to request enrollment in a bunch well being plan
  • the timeframes for submitting claims below the plans claims-processing procedures
  • the deadlines for requesting inside and exterior appeals for opposed profit determinations
60 days after the tip of the § 201 nationwide emergency Statutory timeframes would resume 60 days after the tip of the § 201 nationwide emergency. These timeline extensions might have been extra helpful when the temporary COBRA subsidies had been in impact, however these have now expired.

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Description Expiration Implications
The FDA has issued EUAs for tons of of COVID-19 checks, quite a few COVID-19 remedies, together with antiviral brokers and monoclonal antibodies, and three COVID-19 vaccines (Pfizer, Moderna, and Johnson & Johnson). EUAs permit medical countermeasures to be accessible to the general public earlier than formal FDA approval. Finish of § 564 emergency declaration (to be decided by the Secretary) Any COVID-19 medical countermeasure nonetheless below an EUA will no longer available for use. A transition interval will permit for disposition of unapproved merchandise coated by EUAs in addition to labeling and different materials associated to unapproved makes use of of authorized merchandise.

As of April 6, 2022, the FDA has authorized two COVID-19 vaccines to be used amongst adults (Pfizer: ages 16+, and Moderna: ages 18+), however for youthful age teams, use of those vaccines continues to solely be allowed below EUAs.

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Description Expiration Implications
Liability immunity has been prolonged to suppliers primarily based on the PREP Act emergency declaration to permit for larger supply of and entry to medical countermeasures. For instance, legal responsibility immunity has been prolonged to:

  • pharmacists and pharmacy interns to manage COVID-19 vaccines (and different immunizations) to youngsters between the ages of three and 18, pre-empting any state regulation that had age limits
  • healthcare suppliers licensed in a single state to vaccinate in opposition to COVID-19 in any state
  • physicians, registered nurses, and sensible nurses whose licenses expired inside the previous 5 years to manage COVID-19 vaccines in any state
Finish of PREP Act declaration: October 1, 2024 Legal responsibility protections will not be accessible except a state offers such protections and authority below state regulation.

With out such authority, entry would doubtless be diminished, as many suppliers would not be capable to present medical countermeasures coated by the declaration.

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