End of Public Health Emergency Triggers End to Medicare, Medicaid Flexibilities

While the country looks forward to the end of the COVID-19 pandemic to get back to a sense of normalcy, there are concerns that the end of the public health emergency (PHE) will trigger the end of waivers and regulations in Medicare and Medicaid that could significantly impact patients, explained Mark Hamelburg, senior vice president of federal programs at AHIP, during an AHIP webinar on the state of the industry in 2022.

Hamelburg was joined by fellow AHIP experts Kate Berry, senior vice president of clinical innovation; Danielle Lloyd, senior vice president of private market innovations and quality initiatives; and AHIP CEO and President Matt Eyles.

Eyles kicked off the webinar to highlight some of AHIP’s priorities in 2022:

• Ensuring access to affordable coverage and care by addressing the underlying cost drivers of care
• Ending pharmaceutical monopolies and patent gaming that let companies raise drug prices, shut out competition from generics and biosimilars, and undermine the ability to negotiate for lower drug prices
• Improving health equity so everyone has an equal opportunity to achieve their best health
• Developing a clear vision of a postpandemic world that maintains coverage gains and marketplace subsidies that have made health insurance coverage affordable
• Supporting a competitive, free market, which had ensured early access to COVID-19 testing and treatment without a cost barrier

“We are champions of care in 2022 and beyond, and our focus is squarely going to be on the health and well-being of Americans,” Eyles said. “It is top of mind for us at AHIP here every single day.”

As the pandemic and PHE come to an end, there are going to be important shifts for people who qualify for Medicare and Medicaid, Hamelburg explained. At the start of the pandemic, the government implemented COVID-19 relief laws and regulatory flexibility that will end with the PHE.

In Medicare, enrollees have paid no cost sharing for their COVID-19 testing and related services, as well as monoclonal antibody infusions for COVID-19 treatment, he said. In Medicare Advantage (MA) and Part D, regulations enacted during the PHE have allowed enrollees to access out-of-network coverage at in-network cost-sharing levels.

Other provisions that will end with the PHE include flexibilities for MA plan sponsors to waive or reduce premiums and make mid-year benefit enhancements during the PHE, Hamelburg said.

Medicaid also has a requirement tied to the PHE around ensuring all states provide coverage without cost sharing for COVID-19 vaccines, testing, and treatment. There are also a number of operational waivers that states received to run their Medicaid programs during the PHE.

“Maybe one of the most significant impacts that we'll have—potential shifts across different programs and products—relates to eligibility in Medicaid,” Hamelburg said.

At the beginning of the PHE, states were given an increase in their federal Medicaid matching funds as long as states agreed to maintain their Medicaid eligibility for beneficiaries through the end of the PHE. This means states have not been doing regular eligibility reviews and rolling people off when they no longer qualify.

“So, now we've gone through almost 2 years [of the PHE], and incomes and other conditions have changed, and some people are no longer going to be eligible,” Hamelburg explained. “In fact, we now have more than 80 million people on Medicaid and CHIP. And there have been estimates that millions could end up losing coverage when this process kicks in.”

A major concern is that people who lose coverage, or even those who remain eligible, could run into issues because of processing delays. States may not have their updated addresses and people could lose coverage even though they are still eligible.

“That's something that we are tremendously focused on and is going to be one of the big issues once the PHE ends,” he said.

Separate from the pandemic, Hamelburg highlighted the success of the MA program. At this point, there are almost 29 million people in MA, which is roughly 45% of all Medicare beneficiaries. He also noted that the enrollees in MA are more racially and ethnically diverse, as well as being more satisfied with their coverage than enrollees in traditional Medicare.

According to Hamelburg, MA gives enrollees more financial security at a more affordable price and research has shown that there are positive clinical outcomes for people in MA vs traditional Medicare. MA enrollees may be getting Part D drug coverage or dental, vision, and hearing benefits without paying an extra monthly premium. MA also has a cap on annual out-of-pocket costs that is not in the original Medicare program.

“So, people enroll in the program, they're satisfied with it, they talk to others, and that's really generating the incredible growth we've seen,” he said.