By Travis Broome, MPH, MBA, Senior Vice President, Policy & Economics
The White House has announced the Public Health Emergency will end on May 11, 2023. We break down what that means below. Lots to cover so you might want a cup of coffee before digging in.
- Medicare continues to pay for telehealth: The Consolidated Appropriations Act of 2023 extended a number of telehealth flexibilities from the PHE through 2024. These include allowing Medicare beneficiaries in any geographic area to receive telehealth, allowing beneficiaries to remain in their home for telehealth visits, allowing FQHCs/RHCs to serve as a distant site provider, and allowing more health care professionals to provide telehealth services (such as physical and occupational therapists), delaying the in-person visit requirement before a patient receives mental health services via telehealth, and allowing for audio-only services.
- Physicians must report their home address on their Medicare enrollment if they continue to provide telehealth from their home: What was not extended in the CAA: when the PHE expires, the only way physicians and other practitioners can continue to bill for telehealth from their home is if they report their home address on their Medicare enrollment. Practitioners will be required to either resume reporting on their home address on the Medicare enrollment or they will have to stop billing for telehealth provided from their home. The guidance from CMS is on page 14. CMS guidance on managing your enrollment is here. The revised definition of direct supervision to include a virtual presence through the use of interactive telecommunications technology will also end with the PHE.
- Medicaid patients face enrollment verification starting April 1st: The PHE included a requirement that Medicaid programs keep people continuously enrolled through the end of the last month of the PHE, in exchange for enhanced federal funding. The CAA set an end to the continuous enrollment provision on March 31, 2023, directing states to begin phasing down the enhanced federal Medicaid matching funds through December 2023. States that accept the enhanced federal funding can resume disenrollment beginning in April but must meet certain reporting and other requirements during the unwinding process.
COVID-19 Tests and Treatments
- Deductibles and co-insurance will apply to COVID testing and treatment: During the PHE, Medicare beneficiaries do not have cost-sharing for COVID-19 at-home tests (up to 8 per month), testing-related services, and certain treatments. The CAA extended coverage for Paxlovid/oral antivirals. Medicare will still cover testing, but the no-cost-sharing provision ends with the PHE. Vaccines will still be available with no cost sharing.
- Private insurers can also resume cost sharing for tests and treatments: The free access to treatments is not tied to the PHE, so treatments like Paxlovid will still be free as long as the federal government is supplying them. Private plans will still be required to cover any vaccine recommended by ACIP with no cost-sharing (in-network), per the ACA.
- COVID-19 costs no longer excluded: During the PHE, all costs during an episode of care are excluded from ACO calculations. An episode of care is defined through claims as being a claim type 60, having diagnosis codes equal to B97.29 or U07.1, and having a hospital discharge date between January 27, 2020, and the expiration date of the PHE. While this will increase costs for our ACOs, it will also increase the trend updates to our benchmarks. This will only reduce our savings if we underperform on care for COVID-positive patients compared to the average. We expect to continue to outperform as we have been doing since the pandemic began.
- Shared losses are prorated: Under the Extreme & Uncontrollable Circumstances Policy, the amount of the ACO’s shared losses is prorated by the amount of the year and the beneficiaries affected by the PHE. For years when the COVID PHE was in effect for the full 12 months, there are no shared losses. This year losses will be prorated to 58%. Obviously, this only matters if an ACO has losses. No Aledade ACO has ever had to repay shared losses in the MSSP.
- Quality measurement returns to normal scoring: Under the PHE an ACO received the higher of their earned quality score or the minimum to be eligible for savings. Every Aledade ACO in every year of the pandemic has greatly exceeded the minimum and used its earned quality score. We are certain 2023 will be no different and our quality will remain excellent.