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The United States declared a public health emergency (PHE) in January 2020. Over the course of the COVID pandemic, a series of laws were passed to assure that people could continue to access the healthcare services they needed. For Medicare, that meant covering COVID-19 tests and vaccines, expanding telehealth services, and more.
With the recent announcement that the PHE will end on May 11, 2023, access to some of those healthcare benefits may be costlier or more complex. As a Medicare beneficiary, this is what you need to know.
Medicare covers only vaccines that have been granted full approval by the FDA. Given the nature of the pandemic, however, several vaccines had emergency use authorization based on early clinical data although they did not yet have the data to support full approval.
Currently, only the Pfizer and Moderna mRNA-based COVID vaccines have full FDA approval in the United States. After the PHE ends, these are the only COVID-19 vaccines that will be covered by Medicare. Thanks to the CARES Act, these vaccines, including any booster shots, will be covered by Medicare Part B. They will be free to you (i.e., there will be no cost-sharing) as long as your healthcare provider accepts assignment.
Because Medicare Advantage plans cover everything that Part B does, they will cover these vaccines as well. There could be costs associated with the vaccine if you get your vaccine outside of your plan’s network.
During the PHE, the federal government allowed you to get eight free at-home COVID-19 testing kits each month. This was the case whether you had Original Medicare (Part A and Part B) coverage or a Medicare Advantage plan (Part C).
Original Medicare does not traditionally cover over-the-counter health-related items. After the PHE, you will pay for any at-home COVID tests out of pocket.
COVID tests that are ordered by a healthcare provider and that are performed in an office or laboratory setting will continue to be free under Part B when you are on Original Medicare. If you are enrolled in a Medicare Advantage plan, however, there could be cost-sharing. Coverage and costs will depend on your plan.
During the PHE, the Families First Coronavirus Response Act removed cost-sharing for services related to COVID testing. That could include, but was not limited to, care you received in a medical office, telehealth visit, emergency room, or urgent care clinic that led to you getting a COVID test.
After the PHE ends, you will be responsible for costs – including any deductibles, copays, or coinsurance – for these visits and associated services. As noted above, the COVID test itself will be free to you if you are on Original Medicare.
During the PHE, Medicare Advantage (MA) plans could not charge you more for care you received out of network. A CMS waiver also made it unnecessary for MA enrollees to get physician referrals for necessary care.
That will change 30 days after the PHE ends. Unless there is an ongoing emergency where you live (i.e., at a local, state, or federal level), your Medicare Advantage plan will be able to charge more for out-of-network care or even deny coverage for that care altogether. MA plans may also require referrals in certain circumstances.
During the PHE, Medicare covered all costs for monoclonal antibody treatments and oral antiviral treatments to treat your COVID infection.
The Consolidated Appropriations Act of 2023 extended coverage for oral antiviral medications through December 31, 2024. All other treatments will require cost-sharing after the PHE ends. Please know that not all COVID-related medications will necessarily be covered by your Part D plan.
Before the pandemic, Original Medicare had restrictions on telehealth use. To take advantage of telehealth, you had to be in a rural area and, with few exceptions, the services had to be completed at a designated medical site (i.e., a community health center, a doctor’s office, a hospital, a qualifying dialysis facility, a skilled nursing facility, etc.).
The only time you did not have to be in a rural setting was when you had a telehealth visit for a stroke, received dialysis at home, or received treatment for a substance use disorder or other mental health condition. Home visits were allowable for the latter two telehealth types but only if in-office visits had occurred within a designated time frame.
Telehealth visits also had to be performed using HIPAA-compliant audio-visual technology. To make it easier to access care, the HIPAA-compliance requirement was lifted during the PHE, audio-only telehealth visits were allowed, and you could access care from home no matter where you lived. The number of services covered via telehealth also expanded to include care from audiologists, physical therapists, occupational therapists, speech therapists, among others.
Once the PHE ends, the HIPAA-compliant requirement will come back into play. Not all healthcare facilities may be prepared to accommodate the change which could affect your access to care in some cases.
Audio-only visits, expanded geographic coverage, and the types of care offered through telehealth will continue as they currently stand through December 31, 2024. After that, it’s possible your utilization of telehealth may be restricted to care in rural areas, from designated medical sites, and with fewer covered services, similar to what existed before the pandemic. Unless you are receiving care for a mental health condition (in which case enrollees can utilize audio-only visits), telehealth visits will require audio-visual technology in 2025 and beyond.
Medicare Advantage plans must offer all the telehealth services that Part B covers but they can offer additional telehealth services as a supplemental benefit. This extra coverage may provide access regardless of where you live and more services may be available from your own home.
If interested, you should reach out to your Medicare Advantage plan to find out what kinds of telehealth services they cover.
Tanya Feke M.D. is a licensed, board-certified family physician. As a practicing primary care physician and an urgent care physician for nearly ten years, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance. She currently works as a physician advisor at R1 RCM, Inc., where she performs case reviews for hospitals nationwide.
Dr. Feke is an authority in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authored Medicare Essentials: A Physician Insider Reveals the Fine Print. She has been frequently referenced as a Medicare expert in the media and is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.