COVID-19 Coverage Ending: What's Changing

On Jan. 30, 2023, the Biden Administration announced its intent to end the national emergency and public health emergency declarations on May 11, 2023, related to the COVID-19 pandemic. These emergency declarations have been in place since early 2020, and gave the federal government flexibility to waive or modify certain requirements in a range of areas, including in the Medicare programs, and in private health insurance.

“People will have to start paying some money for things they didn’t have to pay for during the emergency,” said Jen Kates, senior vice president at the Kaiser Family Foundation. Here’s more helpful information provided by KFF. 

How You Might Be Affected:

Under 65 INDIVIDUAL AND GROUP

NOW: Group health plans and individual health insurance plans are required to cover COVID-19 tests and testing-related services without cost sharing or prior authorization or other medical management requirements. THIS ENDS MAY 11, 2023

NOW: Group health plans and individual health insurance (including grandfathered plans) must reimburse out-of-network providers for tests and related services. THIS ENDS MAY 11, 2023

NOW: Beginning January 15, 2022, this requirement applies to over-the-counter (OTC) COVID-19 tests authorized, cleared, or approved by the FDA. Health plans must cover up to 8 free OTC at-home tests per covered individual per month, and no physician’s order or prescription is required. Plans may limit reimbursement to no less than the actual or negotiated price or $12 per test (whichever is lower). Plans can set up a network of providers, such as pharmacies or retailers, to   OTC tests for free rather than having patients to pay up front and submit claims for reimbursement, but the coverage requirement applies whether or not consumers get tests from participating providers. THIS ENDS MAY 11. 2023

NOW: Plans and issuers must cover COVID-19 vaccines without cost sharing even when provided by out-of-network providers and must reimburse out-of-network providers a reasonable amount for vaccine administration; federal regulations specify the Medicare reimbursement rate for vaccine administration is a reasonable amount. THIS ENDS MAY 11, 2023

Medicare 

NOW: Beneficiaries in traditional Medicare and Medicare Advantage pay no cost sharing for COVID-19 at-home testing (up to eight tests per month), testing-related services, and certain treatments, including oral antiviral drugs (such as Paxlovid). THIS ENDS MAY 11, 2023, except coverage and costs for oral antivirals, where changes were made in the Consolidated Appropriations Act (CAA), 2023

NOW: Medicare Part D plans (both stand-alone drug plans and Medicare Advantage drug plans) must provide up to a 90-day (3 month) supply of covered Part D drugs to enrollees who request it.

THIS ENDS MAY 11, 2023

NOW: Congress has extended all current support of telehealth services covered by Medicare through December, 2024

Keeping Informed

Your pharmacist, doctor’s office and hospital insurance department should always be your first source of information for pricing and coverage.

For Under 65 individuals and group members, call the number on your membership card to confirm what your plan covers.

For Over 65, call the number on your Medicare Supplement or Medicare Advantage card.

Please note: Because of HIPAA laws, Jerry S. Pearlstein Insurance cannot get information concerning your personal prescriptions or areas of treatment.