The end of the COVID-19 public health emergency on May 11 has created dizzying changes for Medicare beneficiaries.
Whether Medicare will or won’t cover certain health care costs may now depend on whether you are in Traditional Medicare or a private insurer’s Medicare Advantage plan, want remote monitoring for a chronic condition, and need rehab in a skilled nursing facility.
The Trump administration initially declared the coronavirus a public health emergency in January 2020. Although COVID-19 was the fourth leading cause of death in the United States last year and more than 1,000 Americans die from it weekly, the new phase of the pandemic has led the U.S. government to relax its health care rules.
Here’s what Medicare beneficiaries need to know about their new world of health insurance coverage:
Higher costs for Medicare Advantage out-of-network doctor visits
During the public health emergency, Medicare Advantage plans weren’t allowed to charge more if members saw out-of-network physicians. “But those protections will end, and people will once again either have to pay more or not have coverage depending on their Medicare Advantage plan,” says Juliette Cubanski, the San Francisco-based deputy director of the Program on Medicare Policy at KFF, a health policy research and news nonprofit.
“If people started seeing a provider who’s not in their Medicare Advantage plan’s network and expect to continue to see that provider, they may face the reality that it will come with a higher price tag,” she adds.
Continued coverage for telehealth (mostly)
“The good news is that Medicare beneficiaries receiving telehealth will be able to do so through at least December 31, 2024,” says Erin Whaley, health sciences partner at the Troutman Pepper law firm in Roanoke, Va.
Telehealth is largely unaffected by the end of the public health emergency because of a 2023 law extending Medicare’s telehealth coverage through next year. So, you’ll still be covered for a telehealth appointment, including one with an audiologist, occupational therapist, physical therapist or clinical psychologist.
But there are two exceptions.
One is for remote monitoring for chronic and acute conditions. Medicare beneficiaries are now only covered for telehealth monitoring of, say, a continuous glucose monitor for diabetes if they are already patients of the doctor providing this care, notes Whaley.
“That’s changing back to the pre-pandemic rules, where you could only get remote monitoring if you were an ‘established’ patient,” she says. If you don’t have a doctor for remote monitoring, you now need to find one to become an established patient, she adds.
The other exception: Medicare no longer pays for routine home care through telehealth under the program’s hospice benefit, according to CMS.
The end of free at-home COVID-19 tests
“The main area where people on Medicare are likely to notice changes is if they go to get COVID-19 tests from a pharmacy or do at-home testing,” says Cubanski.
Since April 2022, Medicare beneficiaries could get eight free at-home COVID-19 tests a month. Now, Medicare will no longer cover at-home tests for people in Traditional Medicare, Cubanski says. A KFF analysis found the average cost of an at-home rapid COVID-19 test is now $11.
“The convenience of at-home testing has really enabled people to test whenever they want to get together with their friends or family and know—with whatever certainty you get from the at-home test—whether or not you are infectious and maybe potentially risking exposing other people in your life who may be immunocompromised or have other conditions that predispose them to serious illness if they get infected.”
Each Medicare Advantage plan, however, will decide whether to keep offering these tests for members. “It’s not a requirement, it’s an option,” says Cubanski. “I think CMS [the Centers for Medicare and Medicaid Services] is certainly encouraging Medicare Advantage plans to continue to offer this as a supplemental benefit. It seems reasonable to think that a lot of plans covering it as an over-the-counter benefit will continue to do so.”
New rules for COVID-19 PCR and antigen tests
Medicare will still cover COVID-19 PCR and antigen tests given in approved laboratories and ordered by doctors.
People on Traditional Medicare still won’t have to pay for these tests. But they may have to pay for the doctor visit resulting in the prescription for the test, Cubanski says.
Some Medicare Advantage plans may charge members for PCR and antigen tests and associated doctor visits or require the tests be done by in-network doctors.
No changes for COVID-19 vaccines
COVID-19 vaccines will still generally be free to people on Traditional Medicare, as long as the U.S. government stockpile has them and your doctor takes Medicare. Medicare Advantage plans won’t charge for COVID-19 vaccines either, if you go to one of their in-network providers.
“When the government supply of COVID-19 vaccines runs out and the supply shifts to the private sector, the beneficiary cost will still be zero,” says Cubanski.
Paxlovid: free for now
Paxlovid, an antiviral drug use to treat people with COVID-19 will still be free—as long as the government’s supply lasts.
When the Paxlovid stockpile ends, Medicare beneficiaries with Part D Medicare prescription drug plans will be able to get the treatment for free through December 2024. But those without Part D plans may start owing co-pays for the treatment.
Concern about ‘the three-day rule’
Experts at LeadingAge, a group representing over 5,000 nonprofit aging services providers, say a big change for some beneficiaries with Traditional Medicare is the return of what’s known as “the three-day rule.”
During the public health emergency, Medicare waived the rule that required people be admitted into hospitals for at least three consecutive days before Medicare would cover a subsequent stay in a skilled nursing facility for, say, rehab.
The waiver, Whaley says, was partly to avoid overcrowding in hospitals during the pandemic. It sometimes helped Medicare beneficiaries with injuries from falls get rehab treatment in skilled nursing facilities.
But the three-day rule is now back.
As a result, “you could be paying fully out of pocket for care in a skilled nursing facility because you didn’t meet the minimum stay requirement before you were discharged,” says Cubanski. (Medicare Advantage members are excluded from the three-day rule if they go to in-network facilities.)
The three required days in the hospital don’t include days when a patient is in the medical center “under observation,” but not technically admitted. “That’s why it’s really important for people to understand, when they’re in the hospital, ‘Is this day an observation day or an actual inpatient day?” says Cubanski.
Requiring a hospital stay of three days or longer before being transferred to a skilled rehab facility, critics say, delays necessary care and can lead to extra out-of-pocket costs for people in Medicare. LeadingAge says lengthening hospital stays can be challenging for older people, especially ones with cognitive impairments.
The American Health Care Association/National Center for Assisted Living told Skilled Nursing News in a statement: “For years we have advocated to eliminate this confusing policy barrier by recognizing observation stays as qualifying stays for the purposes of the three-day stay requirement or eliminating the three-day requirement all together.”
LeadingAge has urged the Department of Health and Human Services (HHS) to make permanent the waiver of the three-day requirement and Congress to end the requirement entirely.
“In the more than half-century since the requirement was adopted, a growing body of evidence and experience has proven that automatically requiring a three-day inpatient hospital stay is unreasonable, unnecessary, irresponsible and inequitable,” LeadingAge president and CEO Katie Smith Sloan said in a statement sent to Congress and HHS.
The end of the three-day rule, some experts say, will lead some Medicare beneficiaries to go from the hospital to home care rehab, since Medicare often pays for that.
