President Biden has announced the conclusion of the COVID-19 National Emergency and the Public Health Emergency (PHE), under Section 319 of the Public Health Service (PHS) Act, as of May 11, 2023.
The PHE was announced at the beginning of 2020, giving the federal government flexibility to waive or modify certain requirements in a variety of areas, including self-insured health plans. Additionally, Congress enacted several laws in response to the PHE declaration —including the Families First Coronavirus Response Act (FFCRA), the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the American Rescue Plan Act (ARPA), the Inflation Reduction Act (IRA), and the Consolidated Appropriations Act, 2023 (CAA). These pieces of legislation provided additional flexibility tied to one or more of these emergency declarations, and as such they are set to expire when or at a specified time after the emergency period expires.
Impact On Self-Insured Health Plans
As you know, during the PHE, plans were required to cover COVID-19 testing and related services without cost-sharing for both in-network and out-of-network providers, prior authorization, or other medical management requirements. In January 2022, the federal government expanded the mandate by requiring health plans and insurers to cover OTC COVID-19 test kits at retail pharmacies as a part of their pharmacy benefit with no upfront cost to the member. Following the expiration of the PHE, these mandates no longer apply.
This will provide plans with some flexibility in plan design regarding COVID-19 diagnostic testing and other related services. Plans may continue coverage of COVID testing, including OTC tests, without cost share if they choose to do so, subject to their Pharmacy Benefit Manager’s ongoing capability to manage such benefits. It is important to note that coverage for testing without cost-sharing will automatically end on May 12, 2023. Alternatively, plans may choose to cover COVID-19 testing the same as all other laboratory tests.
The end of the PHE also impacts coverage requirements for COVID-19 vaccines. During the PHE, all grandfathered and non-grandfathered plans were required to cover COVID-19 vaccines, including booster doses, from out-of-network providers, without prior authorization, or other medical management requirements. For grandfathered plans, this requirement will no longer apply. For non-grandfathered plans, however, coverage of in-network COVID-19 vaccines without cost sharing will continue to be required under the Affordable Care Act’s preventive services coverage mandate. Out-of-network vaccine coverage is no longer required.
Impact to Providers
It is important to note that the employer groups MedCost works with can be either grandfathered or non-grandfathered plans, with potential varying coverage. Members may be responsible for covering costs that include copayments, coinsurance, and deductible amounts. It is recommended that you verify benefits and collect the necessary amount from the member at the time of service.