What Does the End of the Public Health Emergency Mean for Healthcare Payors?

Vaccination and Preventive Services Coverage

Early in 2020, Congress passed the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and the Families First Coronavirus Response Act (FFCRA) in response to the COVID pandemic. This legislation required COVID vaccines, vaccine administration, and other qualified preventive services to be free during the PHE and prohibited the imposition of cost sharing for individuals receiving these services. When the PHE ends, coverage for vaccines and related services will shift to traditional healthcare coverage. However, COVID vaccines will remain a preventative health service that must be covered by most insurers without cost-sharing under the rules of the Affordable Care Act (ACA), because they are recommended by the Advisory Committee on Immunization Practices (ACIP).here

Government Plans

Medicaid will continue to cover COVID vaccinations without cost-sharing through September 30, 2024. Thereafter, vaccines recommended by ACIP, including COVID vaccines, will continue to be covered without requiring member cost sharing for most Medicaid enrollees. Medicaid will cover COVID treatment without cost-sharing through September 30, 2024.

Uninsured Access to Vaccines

The end of the PHE means that uninsured individuals will no longer be able to access government-funded vaccines.  However, Moderna has announced its COVID vaccines will remain free to the uninsured in the United States through their patient assistance program.  Pfizer also has a patient assistance program that may cover its COVID vaccines.

Diagnostic Testing

During the PHE, a combination of the FFCRA and the CARES Act required commercial insurance to cover diagnostic COVID tests as well as related services received during the relevant office/telehealth visit without any cost-sharing with the individual. Once the PHE expires, plans will no longer be prohibited from imposing a cost share obligation for these tests.

The CARES Act also established a reimbursement requirement for diagnostic testing during the PHE. Negotiated rates in place before the PHE had to be used throughout the PHE; if no negotiated rate was in place with a particular provider, the plan was required to reimburse the provider the cash rate listed on the provider’s website, or negotiate another rate. This requirement will expire in May along with the PHE. 

Government Plans

For Medicare Part B, diagnostic testing ordered by a provider will continue to be provided without cost-sharing, but over-the-counter diagnostic testing will no longer be covered.  Medicaid must cover diagnostic testing without cost share through September 30, 2024.

State-Specific News

In October 2021, California passed a law that requires health plans reimbursement to out-of-network providers for COVID testing to be reasonable. In April 2022, the Department of Managed Health Care announced that 125% of Medicare is reasonable for commercial plans under its jurisdiction.

Claritev will continue monitoring state-legislation to see if other states pass similar laws.

Telehealth Coverage

Congress extended the COVID-related telehealth expansion for Medicare through December 2024.  For Medicaid, state flexibility to cover telehealth services is not impacted by the PHE or its expiration.

Bottom Line

Health plans will have more flexibility in reimbursement, and will be able to impose cost-sharing obligations on certain types of COVID claims, including diagnostic testing claims. Providers will also be able to appeal reimbursement.