An era ends for the U.S. healthcare industry with the termination of the COVID-19 public health emergency (PHE) at the close of the day on Thursday, May 11.
The termination means providers are losing many of the federal waivers and flexibilities that have been in place for all or most of the PHE, which took effect Jan. 31, 2020.
In a separate development, the World Health Organization on May 5 declared that COVID-19 no longer constitutes a global health emergency (WHO leaders noted the change in designation does not mark a formal end to the pandemic).
Not all PHE provisions will be affected immediately. Telehealth and acute care hospital-at-home waivers will remain through 2024 thanks to extensions in FY23 omnibus legislation. Other provisions, such as allowing a supervising clinician to be available virtually instead of on-site, will last through this year.
The biggest ongoing change is the unwinding of Medicaid continuous enrollment provisions, with an estimated 17.4% of beneficiaries losing coverage at least temporarily. The omnibus legislation decoupled the unwinding from the PHE and allowed states to begin the process as early as April 1.
Below are some of the key things for providers to keep in mind regarding the immediate PHE-related changes. For more information, see this U.S. Department of Health and Human Services (HHS) fact sheet and this comprehensive listing of PHE waivers.
The 20% add-on payment for treating COVID-19 cases in the inpatient setting no longer will be available. With reported cases and hospitalizations steadily trending downward, that may not constitute a significant revenue loss. But the margin per case will be affected, especially given the costs of treating COVID-19 patients.
One procedural implication is the need for hospitals to ensure their pricing tools are updated to avoid getting “a bunch of false underpayment variances that are flooding people’s work queues [and] are no longer applicable,” noted Melissa Harbert Miskell, MBA, head of markets and consulting with Revecore, a revenue integrity and claims solutions company.
If such tools are in the form of products that directly license pricing from Medicare, the update should be automatic, she added. However, “Sometimes Medicare doesn’t always put their updates out right on the [first] day. Sometimes it’s a few weeks later, so there might be some retroactive pricing they’ll have to do to get their work queues correct, to make sure those don’t falsely show as underpayments.”
Enhanced payment for new COVID-19 treatments also will cease to be available after May 11.
Medicare will revert to requiring a three-day inpatient stay before covering skilled nursing facility (SNF) care. The change could exacerbate the difficulty hospitals have been having with patient throughput.
Hospitals also won’t be able to provide swing beds for patients who no longer require acute care but cannot find a placement in an SNF, nor may they bill for care furnished to inpatients being housed in “distinct part units.” Conversely, patients whose care is payable under the payment systems for inpatient psychiatric care or inpatient rehabilitation care cannot be placed in an acute care bed.
Regulatory limits on bed counts will return for critical access hospitals, sole community hospitals and Medicare-dependent hospitals. Freestanding emergency departments won’t be allowed to receive Medicare or Medicaid reimbursement.
Also expiring will be a relaxation of requirements for physician credentialing and privileging processes at hospitals and for Medicare patients to be under the care of a physician. In addition, certified registered nurse anesthetists will have to resume being supervised by a physician unless they work in a state that has been granted a waiver extension.
The American Association of Nurse Anesthesiology this week issued a news release warning that reinstating those regulations could affect patient access to care.
The end of the PHE brings a close to the Hospital Without Walls program. The program expanded capacity by allowing a hospital to provide certain outpatient services (downloadable file) in person or remotely in outside facilities that were considered extensions of the hospital — including patients’ homes.
CMS’s 2023 rule for hospital outpatient care established that many behavioral health services furnished remotely will remain payable through the end of this year.
While provisions that expanded telehealth access will continue at least through 2024, hospitals no longer can bill for HCPCS code Q3014 (originating-site facility fee) unless a Medicare beneficiary is located within a hospital while receiving a telehealth service from an eligible distant-site practitioner.
Payment parity for telehealth services has been in place during the pandemic but is slated to last only through 2023. CMS is expected to set telehealth rates for 2024 in upcoming regulations for Medicare physician payments. Commercial health plans may need to adhere to parity guidelines in some states, whereas in others they can set their own rates.
The U.S. Drug Enforcement Administration has extended until Nov. 11 the provision allowing physicians to prescribe controlled substances via telehealth without first seeing a patient in person.
Hospital data reporting on COVID-19 cases will be required on a weekly rather than daily basis after the PHE. Reporting will continue through at least April 30, 2024, unless HHS amends the end date.
Mandatory time frames will return for scenarios such as reporting a patient death in the ICU and authenticating verbal clinical orders. Hospitals also will have to resume meeting deadlines for completing medical records.
The relaxation of discharge-planning requirements also will end, as will leeway pertaining to:
- Utilization review plans
- Quality-assessment and performance improvement programs
- Nursing care plans
COVID-19 vaccines and tests
Medicare- and Medicaid-certified healthcare facilities before long won’t be subject to the COVID-19 vaccine mandate for staff, the White House stated May 1. The timing and process of phasing out the mandate are to be announced.
For Medicare beneficiaries, some of the biggest changes will affect tests, which after the PHE can be procured with no cost sharing only when ordered by physicians or certain other clinicians. Over-the-counter purchases no longer will be covered, although Medicare Advantage (MA) plans may choose to do so.
CMS will continue to pay providers at a rate of $40 per vaccine dose administered through the end of the calendar year in which the emergency use authorization (EUA) for COVID-19 drugs and biologicals is concluded. The EUA is separate from the PHE and remains in effect. The additional $36 payment per dose administered in patients’ homes will continue through the end of 2023.
Medicare fee-for-service beneficiaries won’t owe out-of-pocket costs for the vaccines, nor will MA beneficiaries if vaccination takes place at an in-network provider.
State Medicaid programs and Children’s Health Insurance Programs must waive cost sharing for COVID-19 vaccines and tests through Sept. 30, 2024.
Most commercial health plans must continue to cover the vaccines without cost sharing when administered by an in-network provider. Coverage of testing no longer will be required.