CMS Issues Payment and Coverage Guidance as Pandemic Waivers Approach Expiration

The agency has issued a fact sheet addressing flexibilities authorized during the COVID-19 federal public health emergency (PHE).

CMS has issued a fact sheet, CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency, which addresses the following areas:

• COVID-19 vaccines, testing, and treatments
   
• Telehealth services
   
• Waiver flexibility
   
• Hospital-at-home care
   
• Provider scope and oversight flexibility
   
• Medicaid continuous enrollment

In the fact sheet, CMS noted the PHE's widespread impact on "many aspects of health care delivery," including those that allowed for more streamlined and flexible services. CMS notes: "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."

COVID-19 updates

Mandatory coverage of COVID-19 services will vary by payer after the PHE expires.

Traditional Medicare beneficiaries will continue to have coverage for vaccines, testing and COVID-19-related treatment. Exceptions include tests that are not ordered by healthcare providers (over the counter) and possible cost-sharing for Medicare Advantage (MA) members.

Among private payers, most must continue to offer no-cost vaccines delivered in network. Mandatory coverage of COVID-19 PCR and antigen tests will expire, will continue at the insurer's discretion, and may involve some cost to members. Treatment coverage and associated cost-sharing and deductibles will not change unless the carrier does so.

For Medicaid members, the American Rescue Plan Act of 2021 (ARPA) required states to "provide Medicaid and CHIP coverage without cost sharing for COVID-19 vaccinations, testing, and treatments." This will expire for treatments and testing by September 30, 2024, and vary by state afterward but will continue for vaccinations.

Telehealth updates

Continued access to and reimbursement of telehealth services will vary by payer after the end of the PHE.

Via the Consolidated Appropriations Act of 2023, original Medicare will retain the following benefits through December 31, 2024:

• General access to telehealth, regardless of where they live and not dependent upon residence in a rural area.
   
• Access to home-based telehealth services versus those delivered in a healthcare facility.
   
• Audio-only telehealth services (e.g., telephone) if other resources are not available (e.g., video, smartphone, computer).

Members of Medicare accountable care organizations (ACOs) may have access to telehealth services after 2024 to ensure continued engagement between patients—no matter where they live—and their PCPs. Primary care is central to value-based care models such as ACOs.

Individual commercial payers—including those who offer MA plans—will determine ongoing telehealth access, coverage, and payment for their members. CMS notes that plans are permitted to "impose cost-sharing, prior authorization, or other forms of medical management on telehealth and other remote care services."  

Medicaid telehealth services will continue to vary as many states offered coverage prior to the pandemic, with continued delivery of services not dependent on the end of the COVID-19 PHE. In its fact sheet, CMS "encourages states to continue to cover Medicaid and CHIP services when they are delivered via telehealth" and has provided a guidance toolkit.

Hospital-at-home updates

CMS implemented the Acute Hospital Care at Home initiative to allow hospitals to provide expanded at-home care during the pandemic. That initiative will stay in place through the end of 2024 as approved by the Consolidated Appropriations Act of 2023. This will allow new patients to participate and maintain continuing for those already receiving at-home care as a part of the program.

Provider updates

Several PHE waivers expanded provider scope of practice and allowed for more flexible training and supervision. The following waivers will expire in 2023, with varying dates:

• Nursing home aides. These providers must once again complete their training within four months of the start of their employment. This requirement will resume with the end of the PHE on May 11, 2023.
   
• Certified registered nurse anesthetists. Practice must return to physician supervision, also effective May 11. States may apply to waive the requirement, allowing CRNAs to practice independently. To be approved, states must "attest that they consulted with the State Boards of Medicine and Nursing … and concluded that it is in the best interest of the citizens of the state to opt-out of the current supervision requirements" in a manner consistent with state law.
   
• Virtual supervision. Physician supervision, where required, must return to direct versus virtual means as of December 31, 2023.

Waiver updates

CMS has issued individual fact sheets for how the end of the PHE will impact waivers related to healthcare providers, settings, and service delivery. Three of note—which CMS states "were intended to temporarily expand health care capacity when needed and generally cannot be made permanent without a legislative change"—include the waiver of:

• Three-day prior inpatient hospitalization for Medicare coverage of a skilled nursing facility (SNF) stay.
   
• Limitations for Critical Access Hospitals (CAHs), including the number of inpatient beds (25) and length of stay (no longer than 96 hours on average).
   
• What constitutes an allowable setting for acute care (expanded to ambulatory surgery centers, inpatient rehabilitation hospitals, hotels, and dormitories during the PHE).

Medicaid enrollment updates

Continuous enrollment for Medicaid members will end March 31, 2023. Continuous enrollment allowed members to stay enrolled in the program without a redetermination process due to the shifting socioeconomic landscape that COVID-19 created.

How states will resume redeterminations is an ongoing topic, including flexibilities that will allow members to stay enrolled without processes that add burden to both states and individuals. States have up to one year to resume standard eligibility and enrollment operations. 

CMS will publish ongoing PHE guidance on its Emergencies Page.