Searching for a New Normal: How Expiration of the Federal Public Health Emergency Impacts Access to Health Care Services

After more than three years, the federal COVID-19 public health emergency (PHE) is set to expire on May 11, 2023. Once the PHE designation is lifted, a number of federal policies intended to help the U.S. health care system adapt to the pandemic will also expire.* One major pandemic relief policy—the requirement to maintain coverage for Medicaid enrollees—was “delinked” from the PHE by Congress, and the “unwinding” process is already well underway in some states. However, other flexibilities will end when the PHE expires, including policies concerning COVID-19 related services, telehealth, and other care delivery models that many consumers have become accustomed to during the pandemic. This post updates CHIR’s review of selected policies tied to the PHE and evaluates how the impending expiration will impact consumers’ access to services.

Access to COVID-19 Related Services

Some of the federal requirements for insurers to cover COVID-19 testing, vaccinations, and treatment will sunset after the PHE ends.

COVID-19 testing. Accessing affordable COVID-19 testing will likely become more challenging for privately insured individuals. The CARES Act of 2020 requires insurers to cover COVID-19 diagnostic testing—without imposing cost-sharing or medical management requirements, such as prior authorization—for the duration of the PHE. Some consumers may soon face cost-sharing or need prior authorization when seeking COVID-19 tests. Private insurers as well as large employer plan sponsors have considerable leeway to decide whether and to what extent to cover COVID testing, although the Department of Labor has encouraged employers and other plan sponsors to continue covering such testing at no cost.

Likewise, insurers will no longer have to continue covering the full cost of up to eight over-the-counter at-home COVID tests per month and plan member. Though implementation of this policy was less than consumer-friendly, consumers will nonetheless lose the guarantee of free testing going forward. With retail prices upwards of $10 per test, and local governments shuttering free test distribution sites, at-home COVID testing could become unaffordable for many Americans.

COVID-19 vaccines. In general, the availability of COVID-19 vaccines is not tied to the PHE, and vaccines will remain free to everyone in the country (regardless of insurance coverage or immigration status) until the federal government’s supply is depleted. Once vaccine distribution shifts to the commercial market—which may happen as soon as this fall—consumers enrolled in non-grandfathered private health plans can still access vaccines at no cost, thanks to the ACA’s preventive services protection. However, consumers will have to ensure they receive vaccinations from an in-network provider to avoid any cost-sharing.

The Biden administration also recently announced a $1.1 billion investment in a “Bridge Access Program” designed to help uninsured populations continue to access free COVID-19 vaccines. The funding will help local health departments and health centers supported by the federal Health Resources and Services Administration (HRSA) continue providing vaccines at no cost, as well as establish a partnership with pharmacy chains through a per-dose payment for provision of vaccines to uninsured patients.

COVID-19 treatment. The Biden administration has committed to maintaining access to COVID-19 treatments, such as Paxlovid, as the provision of COVID services transitions from the federal government to the commercial market. Similar to vaccines, free access to Paxlovid is dependent on the federal supply, not the PHE. While insurers will likely cover COVID-19 treatments to some extent once the government stops footing the bill, consumers could face high out-of-pocket costs (as is already common for many prescription drugs).

Telehealth

Telehealth utilization grew exponentially during the pandemic, particularly among Medicare beneficiaries, whose share of telehealth visits increased 63-fold from 2019 to 2020. The federal government helped increase access to telehealth by allowing providers to deliver care across state lines, waiving certain privacy and security requirements, and permitting reimbursement for telephone-based appointments. Some of these flexibilities that were initially tied to the PHE will remain in place, at least temporarily:

Congress extended many telehealth policies impacting Medicare, either on a permanent basis or temporarily through December 31, 2024. For instance, unlike before the pandemic, Medicare beneficiaries are now permanently eligible to receive telehealth services for behavioral and mental health care from their homes (including through audio-only visits).

After previously allowing HSA-qualified high deductible health plans to cover telehealth services before an enrollee met their deductible, Congress more recently authorized this policy to continue for plan years beginning after December 31, 2022 and before January 1, 2025.

Other telehealth policies will expire with the PHE:

More lax HIPAA enforcement rules regarding telehealth are set to expire on May 11. The federal government exercised discretion to not impose penalties for violations of certain health information privacy rules for the purpose of public health oversight during the PHE. Covered health care providers have a 90-day transition period to come into compliance with HIPAA’s standard telehealth rules. Similar privacy flexibilities for community-based testing sites and online applications for scheduling COVID vaccinations will also expire.

The federal government issued guidance in 2020 allowing insurers to make mid-year changes to their coverage of telehealth services, such as eliminating cost-sharing requirements, without incurring penalties. Nongroup and fully insured group health plans were permitted similar flexibilities. This nonenforcement policy will end with the PHE.

A policy allowing employers to offer telehealth as a stand-alone benefit to employees not eligible for other employer-sponsored coverage will also end. In response, a group of lawmakers in the House have reintroduced the Telehealth Benefit Expansion for Workers Act of 2023, which would establish telehealth as a permanent excepted benefit that is exempt from ACA requirements.

Substance Use Disorder Treatment

The federal government lowered regulatory barriers to providing substance use disorder (SUD) treatment services via telehealth for the duration of the PHE. For instance, during the PHE, providers were newly permitted to prescribe controlled substances, such as buprenorphine, using telehealth without completing an initial in-person patient evaluation. Recent studies have found an association between increased access to telehealth services for opioid-use disorder treatment and better patient adherence to medications, as well as a decreased risk for fatal overdoses.

The future of telehealth rules concerning SUD treatment is somewhat in flux. The PHE flexibilities were originally set to expire with the PHE on May 11. However, the Drug Enforcement Administration (DEA) published a proposed rule in March that would allow providers to continue prescribing controlled substances via telehealth, prior to an in-person evaluation, under limited circumstances, as well as a proposed rule allowing telehealth prescriptions of a 30-day supply of buprenorphine until the patient is seen in-person. Some advocates and lawmakers have expressed concern that the 30-day limit on buprenorphine would lead to potentially fatal care disruptions, particularly for underserved patients in medical shortage areas. In response to these concerns, the DEA announced on May 3 that they are temporarily extending the PHE flexibilities while revisiting their proposed guidance.

Outlook

The COVID-19 pandemic exposed and exacerbated longstanding inequities in our health care system and led to major changes in care delivery. Some reforms that lower barriers to care may be here to stay, but the end of the PHE will also likely result in an increase in financial barriers to COVID-19 services as coverage decisions return to the hands of private insurers. Diagnostic testing is a critical means to mitigate disease transmission, but the end of free testing will result in diminished access and a less effective defense against the spread of the virus. Privately insured consumers will also need to ensure COVID services (tests, vaccines, and treatments) are delivered by in-network providers to avoid higher cost-sharing and potential balance billing. At a time of unprecedented coverage upheaval, stakeholders will have to work together to help consumers navigate this “new normal” of accessing critical health care services.

*Disclaimer: this blog is not intended to cover every COVID-19 relief program, policy, or flexibility that will sunset when the PHE ends, but highlights selected initiatives that are particularly relevant to accessible and affordable care.