What the end of the federal COVID-19 emergency means for healthcare

By Maya Goldman and Mari Devereaux / January 31, 2023

The COVID-19 pandemic may not be over but—after nearly three-and-a-half years—the federal public health emergency is finally set to end. The healthcare system will have a lot of adapting to do.

President Joe Biden announced that he wouldn't renew the declaration, which grants the government broad but temporary powers to alleviate the effects of the coronavirus pandemic on healthcare providers, individuals, health insurers and states, on Monday. The Biden administration last renewed the emergency on Jan. 11 and it will expire May 11.

The public health emergency has been in place since President Donald Trump first triggered it in January 2020. Together with a more sweeping national emergency declaration, the Health and Human Services Department and its constituent agencies were able to waive or ease many healthcare regulations to soften the financial blow on the healthcare system and the patients it serves and to facilitate access to testing, vaccinations and treatments.

With the end of the public health emergency comes the end of these flexibilities. The Centers for Medicare and Medicaid Services started to roll back some waivers last year, such as those related to nursing home operations and telehealth. Other pandemic-era rule changes could be extended or made permanent, either through regulation or legislation.

But without new policymaking, these are the key federal policies that will go away when the public health emergency declaration lapses in four months:

Higher reimbursement for COVID-19 admissions: Hospitals currently receive a 20% boost in Medicare reimbursements for COVID-19 inpatient admissions, which is tied to the public health emergency. But an add-on payment for providing new COVID-19 treatments has been extended until the end of fiscal 2023.

Telehealth: Congress and Biden extended some telehealth flexibilities through 2024, but not every pandemic-related policy was included in the legislation. For example, Medicare currently pays the same for telehealth visits as in-person visits, a provision that will go away at the end of the year because lawmakers didn't extend it. More than 30 states have payment parity rules in place, however, and Congress is considering a two-year continuation of the current reimbursement policy.

Hospital at home: CMS has allowed hospitals to provide acute care to beneficiaries outside of facilities. The program has proven popular, with more than 90 health systems in 34 states participating. Congress extended the Acute Hospital Care at Home initiative through 2024 last month, allowing hospitals to continue receiving waivers and reimbursements for hospital at home.

Medicaid redeterminations: States got a 6.2% bump in their federal Medicaid matching rates because of the pandemic but were not allowed to remove enrollees from the program as a condition of the additional money, even when they no longer qualified for coverage. Once the public health emergency declaration ends, states will be free to resume redeterminations of Medicaid eligibility. HHS projects that 15 million people will lose benefits. States have 14 months to disenroll ineligible people from Medicaid starting April 1. Insurers have been preparing to convert Medicaid members to other forms of coverage, such as subsidized health insurance exchange policies.

COVID-19 test and treatment coverage: During the public health emergency, most private health insurance plans are required to cover COVID-19 tests without cost-sharing. Private insurers and Medicare also pay for up to eight at-home COVID-19 tests per enrollee, per month. Medicaid must cover vaccines, treatment and testing for more than a year after the public health emergency ends. Separately, HHS is offering Eli Lilly's Bebtelovimab, a monoclonal antibody treatment, to uninsured patients at no cost until supplies run out, which is expected this fall.

Workforce: During the public health emergency, CMS allowed for greater staffing flexibility. Nurse anesthetists can work without physician supervision, and nurse practitioners also can do so in some settings. Non-physician practitioners have also been permitted to supervise diagnostic tests. Physicians whose privileges at hospitals or ambulatory surgical centers have expired, or new physicians who haven't gotten full approval yet, can continue practicing at the hospital to assist with COVID-19-related workforce shortages. CMS also allowed virtual supervision of medical residents.

Stark law waivers: Physicians have been able to bypass some self-referral rules during the public health emergency in order to ensure access to care for Medicare and Medicaid beneficiaries.

Discharge planning: CMS waived certain discharge planning requirements for hospitals.

Other administrative tasks: CMS has allowed hospitals significant flexibility when it comes to administrative tasks during the public health emergency. The agency allowed greater use of verbal orders, extended timelines for completing medical records and waived utilization review requirements, among other things.

Physical environment flexibilities: Hospitals have been allowed to use alternative patient care sites, as long as the locations are approved by the states in which they operate.

Skilled nursing facility three-day waiver: Typically, Medicare beneficiaries need to spend three days in a hospital before Medicare will cover nursing home stays. CMS waived this requirement during the public health emergency.

Medicare appeals: During the public health emergency, Medicare contractors and independent review entities can allow providers extensions to file appeals of reviewers' determinations.

Controlled substance prescription: The Drug Enforcement Administration allowed registered providers to prescribe controlled substances via telehealth during the emergency without first evaluating patients in person, which boosted access in rural areas.

HIPAA penalty waivers: HHS used enforcement discretion to waive sanctions against hospitals that don't comply with certain Health Insurance Portability and Accountability Act requirements, such as patients' right to confidential communications.

Emergency Use Authorizations: The Food and Drug Administration is not required to lift its provisional approvals of vaccines, pharmaceuticals and medical devices used on COVID-19 patients when the public health emergency declaration expires.