End of public health emergency triggers end of Medicare and Medicaid flexibilities

As the country eagerly awaits the end of the COVID-19 pandemic to regain a sense of normalcy, there are fears that the end of the public health emergency (PHE) could trigger an end to Medicare waivers and regulations and Medicaid that could have a significant impact on 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 other 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 2022 priorities:

  • Ensure access to affordable coverage and care by addressing the underlying cost drivers of care
  • End pharmaceutical monopolies and patent games that allow companies to raise drug prices, exclude generic and biosimilar competition, and undermine the ability to negotiate lower drug prices
  • Improve health equity so that everyone has an equal chance of being healthier
  • Develop a clear vision of a post-pandemic world that maintains the coverage gains and market subsidies that have made health insurance coverage affordable
  • Support a competitive and open market, which has ensured rapid access to COVID-19 testing and treatment without cost barriers

“We are champions of care in 2022 and beyond, and our focus will be squarely on the health and well-being of Americans,” Eyles said. “It’s a priority for us at AHIP here every day.”

As the pandemic and PHE come to an end, there will be significant changes for those eligible for Medicare and Medicaid, Hamelburg explained. At the start of the pandemic, the government put in place COVID-19 relief laws and regulatory flexibility that will end with the PHE.

In Medicare, enrollees paid no cost sharing for their COVID-19 tests and related services, as well as monoclonal antibody infusions for COVID-19 treatment, he said. In Medicare Advantage (MA) and Part D, regulations passed during the PHE 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 improvements during the PHE, Hamelburg said.

Medicaid also has a PHE-related requirement to ensure that all states provide non-cost-sharing coverage for COVID-19 vaccines, tests, and treatments. There are also a number of operational waivers that states have received to run their Medicaid programs during PHE.

“Perhaps one of the most significant impacts we will have — potential changes between different programs and products — is on Medicaid eligibility,” Hamelburg said.

At the start of PHE, states received an increase in their federal Medicaid matching funds as long as they agreed to maintain Medicaid eligibility for beneficiaries until the end of PHE. This means that states have not conducted regular eligibility reviews and have not removed people when they are no longer eligible.

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

A major concern is that people who lose coverage, or even those who remain eligible, could face problems due to processing delays. States may not have their addresses updated and people may lose coverage even if they are still eligible.

“It’s something we’re very focused on and will be one of the big issues once the PHE is finished,” he said.

Regardless of the pandemic, Hamelburg highlighted the success of the master’s program. At this point, there are nearly 29 million people in MA, or about 45% of all Medicare beneficiaries. He also noted that MA enrollees are more racially and ethnically diverse, while being more satisfied with their coverage than traditional health insurance enrollees.

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 with MA compared to traditional health insurance. MA registrants can get Part D drug coverage or dental, vision, and hearing benefits without paying an additional monthly premium. MA also has a cap on annual disbursements that is not in the original Medicare program.

“So people are signing up for the program, they’re happy with it, they’re talking to others, and it’s really driving the incredible growth that we’ve seen,” he said.

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