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With the end of the federal government’s public health emergency (PHE) looming in 2023, many Americans will soon have to pay some or all of the cost of vaccines, treatments, and tests for COVID-19, according to a new report from the Kaiser Family Foundation (KFF).
Moreover, if Congress doesn’t pass a supplemental emergency funding request from the Biden administration, the federal government will soon deplete its supplies of COVID-19 vaccines, treatments, and tests, according to the report.
At that point, the products will transition to the commercial market. But, without the demand created by federal procurement, it’s uncertain whether drug companies will manufacture an adequate supply of vaccines for the United States.
During the earlier part of the pandemic, Congress passed several bills that required COVID-19 vaccine, treatment, and test coverage by public and private insurers, and the Biden administration issued regulations to protect patient access and promote equitable distribution of these products and services, the report noted.
The effective dates of many of these requirements are tied to the PHE, which was first declared in January 2020 and has been renewed every 90 days since then, most recently on October 13. If the PHE isn’t renewed on January 11, 2023, the temporary protections put in place by Congress will end, some then and others a year later.
The resulting challenges for consumers will be felt most acutely in their access to COVID-19 treatments and tests, KFF pointed out. Vaccines will continue to be available at no cost to all those with insurance, but this will not be the case for treatments and tests, where cost sharing will be widely permitted.
The uninsured and underinsured will be hurt the most, the report states. The uninsured will have limited access to free vaccines and will have no coverage for treatments and tests. Even if consumers have free access or coverage with some cost sharing, they could have limited access to all these types of COVID-fighting products if sufficient supplies are not available from manufacturers.
Below is a summary of the report’s findings as they apply to people with different kinds of insurance and those who are uninsured:
Medicare
Medicare covers COVID-19 vaccines, including boosters, at no cost in traditional Medicare and Medicare Advantage (MA) under Medicare Part B. This coverage will continue after the end of the PHE. Currently, Medicare pays providers for vaccine administration, but not for the vaccine itself, since the government distributes it to providers for free.
When the government supply runs out, Medicare will pay providers for the vaccine.
Medicare beneficiaries have no cost sharing for inpatient COVID-19 treatments, including monoclonal antibody treatments and oral drugs such as remdesivir. These therapeutics are covered as part of hospitalization.
But there are copayments for hospital stays in both traditional Medicare and Medicare Advantage. Most MA plans waived cost sharing for COVID-19 treatment in the pandemic’s early stages, but how many of these waivers remain in effect is unknown.
After the federal supply of treatments is exhausted and/or the PHE ends, Medicare beneficiaries will face copayments for most therapeutics. Oral antiviral drugs approved by the US Food and Drug Administration (FDA) will probably be covered under Medicare Part D, with various amounts of cost sharing.
Medicare pays for clinical diagnostic testing under Part B, and home tests are also covered under the PHE. When the PHE ends, clinical tests, but not home tests, will continue to be covered for original Medicare enrollees. MA plan members may face cost sharing for clinical tests, and home tests may not be covered.
Medicaid and CHIP
Medicaid and the Children’s Health Insurance Program (CHIP) cover COVID-19 vaccines and boosters with no cost sharing. The states reimburse providers for the cost of administering the vaccine and receive 100% federal matching payments for these costs.
Provisions in two COVID relief bills require Medicaid and CHIP to cover these vaccines, even when the PHE ends and there is no longer any supply of federally purchased vaccines. But on the last day of the first quarter that begins a year after the PHE ends, the federal match declines to the overall percentage it pays for Medicaid.
Medicaid and CHIP now cover COVID-19 treatments with no cost sharing for full-benefit enrollees under provisions in the American Rescue Plan Act (ARPA). ARPA requires Medicaid and CHIP programs to cover all treatments with no cost sharing through the last day of the first quarter that begins 1 year after the PHE ends.
After that, FDA-approved treatments will be covered but could be subject to cost sharing. Each state determines whether to cover treatments approved under an emergency use authorization (EUA); most COVID medications are still authorized under an EUA, and not the more traditional-track FDA approval.
Under ARPA, Medicaid and CHIP enrollees get COVID-19 tests for free, including home tests. The programs must cover COVID-19 tests through the last day of the first quarter beginning 1 year after the PHE ends. States will then continue to cover COVID-19 testing as a mandatory lab service if the test is ordered by a physician and provided in an office.
Private Insurance
Vaccines are free to those with private insurance while the federal stockpile lasts. Currently, providers can seek reimbursement from private insurers for vaccine administration but can’t bill patients.
Most insurers reimburse providers, partly because the Affordable Care Act (ACA) requires them to cover preventive services, including vaccines. Even if an insurer is not subject to ACA regulations, patients can’t be billed for vaccination if the dose was purchased by the government.
After the PHE ends and/or the federal supply runs out, most privately insured people will continue to pay nothing for vaccines. Under the ACA, COVID vaccines and associated visits will continue to be free for people enrolled in non-grandfathered plans, if the enrollee receives care from an in-network provider.
No federal law addresses private coverage of COVID treatment or setting limits on patients’ out-of-pocket costs, and this won’t change when the PHE ends. But the ACA requires non-grandfathered plans to cover hospitalization, and there are limits on how much plans can impose in cost sharing.
Early in the pandemic, most insurers voluntarily waived out-of-pocket costs for COVID treatment. But they began to reimplement cost sharing in late 2021.
People with private insurance currently receive COVID-19 lab tests without cost sharing and may be reimbursed for up to eight home tests per month. After the PHE ends, many of the privately insured will likely be subject to cost sharing for tests.
While the ACA requires coverage of tests, health plans can require copays because the tests are not recommended by the US Preventive Services Task Force.
The Uninsured
Right now, the uninsured can obtain COVID-19 vaccines for free from any provider who participates in the COVID-19 vaccination program of the Centers for Disease Control and Prevention (CDC).
Fifteen states also have a temporary option to provide Medicaid coverage for COVID-19 vaccines, testing, and treatment for the uninsured, and they receive 100% federal matching funds to cover those costs. This option will end along with the PHE.
When the government supply of vaccines runs out, uninsured children will be able to get vaccines through the CDC’s Vaccines for Children program. There’s also a discretionary program to provide vaccines to uninsured adults at no cost, but it has to be renewed annually by Congress.
In the 15 states with the temporary Medicaid option, the uninsured can obtain treatment services with no cost sharing. In the other states, they’re not required to pay for government-purchased COVID treatments, but can be charged for visits to obtain a prescription or an infusion.
When the PHE expires and the Medicaid option goes away, the uninsured will pay for treatment-related visits; after the government supply of therapeutics runs out, they’ll also have to pay the full cost of COVID drugs and biologics. The same will be true for testing-related services in all states after the PHE ends.
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