CMS Issues Fact Sheet in Preparation for End of PHE

Based on current COVID-19 trends, the Department of Health and Human Services (HHS) is planning for the federal Public Health Emergency for COVID-19 (PHE), declared under Section 319 of the Public Health Service Act, to expire at the end of the day on May 11, 2023. 

The emergency declarations, legislative actions by Congress and regulatory actions across government, including by the Centers for Medicare & Medicaid Services (CMS), allowed for changes to many aspects of health care delivery during the COVID-19 PHE. Health care providers received maximum flexibility to streamline delivery and allow access to care during the PHE. While some of these changes will be permanent or extended due to Congressional action, some waivers and flexibilities will expire, as they were intended to respond to the rapidly evolving pandemic, not to permanently replace standing rules.

This fact sheet will help you know what to expect at the end of the PHE so that you can continue to feel confident in how you will receive your health care. Please note that this information is not intended to cover every possible scenario.

This fact sheet will cover the following:

• Telehealth services
• Health Care Access: Continuing flexibilities for health care professionals
• Inpatient Hospital Care at Home: Expanded hospital capacity by providing inpatient care in a patient’s home

The administration, States and private insurance plans will continue to provide guidance in the coming months. As described in previous communications, the administration’s continued response is not entirely dependent on the COVID-19 PHE. There are significant flexibilities and actions that will not be affected as the country transitions from the current phase of the response. For more information on what changes and does not change across the department, visit  hhs.gov/about/news/2023/02/09/fact-sheet-covid-19-public-health-emergency-transition-roadmap.html.

Medicaid and CHIP

As a result of the American Rescue Plan Act of 2021 (ARPA), states must provide Medicaid and Children’s Health Insurance Program (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 as expected on May 11, 2023, 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. After the ARPA 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

Vaccines: Most forms of private health insurance must continue to cover COVID-19 vaccines furnished by an in-network health care 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.

Testing: After the expected end of the PHE on May 11, 2023, mandatory coverage for over-the-counter and laboratory-based COVID-19 polymerase chain reaction (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.

Treatments: 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.

Access to Telehealth Services

Medicare and Telehealth

During the PHE, individuals with Medicare had broad access to telehealth services, including in their homes, without the geographic or location limits that usually apply as a result of waivers issued by the secretary, facilitated by the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, and the Coronavirus Aid, Relief, and Economic Security Act. “Telehealth” includes services provided through telecommunications systems (for example, computers and phones) and allows health care providers to give care to patients remotely in place of an in-person office visit.

The Consolidated Appropriations Act, 2023, extended many telehealth flexibilities through Dec. 31, 2024, such as: 

• People with Medicare can access telehealth services in any geographic area in the United States, rather than only those in rural areas.
• People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility.
• Certain telehealth visits can be delivered audio-only (such as a telephone) if someone is unable to use both audio and video, such as a smartphone or computer.

Medicare Advantage plans may offer additional telehealth benefits. Individuals in a Medicare Advantage plan should check with their plan about coverage for telehealth services. Additionally, after Dec. 31, 2024 when these flexibilities expire, some Accountable Care Organizations (ACOs) may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live. If your health care provider participates in an ACO, check with them to see what telehealth services may be available.

Medicaid, CHIP and Telehealth

For Medicaid and CHIP, telehealth flexibilities are not tied to the end of the PHE and have been offered by many state Medicaid programs long before the pandemic. Coverage will ultimately vary by state. CMS encourages states to continue to cover Medicaid and CHIP services when they are delivered via telehealth.

To assist states with the continuation, adoption, or expansion of telehealth coverage, CMS has released the State Medicaid & CHIP Telehealth Toolkit and a supplement that identifies for states the policy topics that should be addressed to facilitate widespread adoption of telehealth: medicaid.gov/medicaid/benefits/downloads/medicaid-chip-telehealth-toolkit-supplement1.pdf.

Private Health Insurance and Telehealth

As is currently the case during the PHE, coverage for telehealth and other remote care services will vary by private insurance 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.

For additional information on your insurer’s approach to telehealth, contact your insurer’s customer service number located on the back of your insurance card.

COVID-19 Waivers and Administrative Flexibilities: How Health Care Providers and Suppliers are Affected

For specific details about how health care providers and suppliers should prepare for the end of the COVID-19 PHE, CMS has developed a series of provider-specific fact sheets at cms.gov/coronavirus-waivers. Below are items of high interest that affect many providers.

Standard Blanket Waivers for Disaster Responses

Blanket waivers generally apply to all entities in a provider category (e.g., all hospitals); these waivers have been made available to several categories of providers and will end at the end of the PHE.

CMS typically issues a standard group of “blanket waivers” in response to emergencies or natural disasters. These can include, for example:

• 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 (CAHs) limit the number of inpatient beds to 25 and general limitations on CAH lengths of stay to no longer than 96 hours on average;
• Waivers to allow acute care patients to be housed in other facilities, such as ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories;
• Other waivers.

These waivers were intended to temporarily expand health care capacity when needed and generally cannot be made permanent without a legislative change. Additional information about what blanket waivers were made available during the COVID-19 PHE is available here: cms.gov/coronavirus-waivers.

Hospital at Home

In response to the challenges faced by hospitals because of COVID-19, CMS implemented the Acute Hospital Care at Home initiative, a flexibility to allow hospitals to expand their capacity to provide inpatient care in an individual’s home. Many hospitals and individuals participated in this initiative—there is broad geographic distribution of hospitals participating, ranging in size and services from small rural settings to large academic settings. The number of approved hospitals in each state varies.

Under the Consolidated Appropriations Act, 2023, the Acute Hospital Care at Home initiative has been extended through Dec. 31, 2024. Hospitals can continue to apply to participate in the initiative. If an individual is receiving care in a participating hospital and meets the requirements to receive inpatient care at home, they can continue to do so.

Virtual Supervision

To allow more people to receive care during the PHE, CMS temporarily changed the definition of “direct supervision” to allow the supervising health care professional to be immediately available through virtual presence using real-time audio/video technology instead of requiring their physical presence. CMS also clarified that the temporary exception to allow immediate availability for direct supervision through virtual presence also facilitates the provision of telehealth services by clinical staff “incident to” the professional services of physicians and other practitioners. This flexibility will expire on Dec. 31, 2023.

Health and Safety Requirements

A significant number of emergency waivers related to health and safety requirements will expire at the end of the PHE, which is expected to be on May 11, 2023. For example, during the PHE, the time frame to complete a medical record at discharge was extended because the large volume of patients being treated would result in the clinician being away from direct patient care for extended periods of time. Typically, a patient’s medical records are required to be completed at discharge to ensure there are no gaps in patients’ continuity of care. This means each provider should have the most up-to-date understanding of their patients’ medical records.

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.