COVID

Starting May 11, payers will no longer have to cover any COVID-19 polymerase chain reaction (PCR) testing with no cost sharing for members, or reimburse members who purchase over-the-counter COVID tests. It’s one of many health care policy changes dictated by the planned end of the federal COVID public health emergency (PHE) on that date. Experts tell AIS Health, a division of MMIT, that the transition will likely cause PCR test prices to fall.

The Families First Coronavirus Response Act and the CARES Act, both passed in 2020, require private health insurers to cover coronavirus tests, with no cost sharing, as well as any services associated with those tests (such as administrative fees), per an expansive reading of both laws implemented by the Biden administration starting in 2021. During 2020, the incumbent Trump administration had required coverage only for “medically necessary” tests ordered by a practitioner. In addition, the Biden administration starting in January 2022 required health plans to reimburse members for up to eight at-home tests per month.

The COVID-19 public health emergency (PHE) will end on May 11, the Biden administration said. Emergency authorities flowing from the PHE have required insurers to make certain COVID-19 testing and treatment available to plan members at no additional cost; expanded access to telehealth in Medicare, Medicaid and CHIP; increased funding to states for Medicaid; and barred states from disenrolling Medicaid members. In December, Congress authorized states to begin disenrolling Medicaid members starting in April, with enhanced funding declining and zeroing out on a set schedule starting then. The Biden administration’s announcement comes as Republicans, newly in control of the House of Representatives, have introduced bills that would end the PHE much sooner. The May 11 end date “align[s] with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the PHE,” according to a White House statement.

Three years after states’ annual efforts to verify enrollees’ Medicaid eligibility were paused because of the COVID-19 public health emergency (PHE), states as of April 1 may begin terminating Medicaid coverage for individuals who no longer qualify. States and their managed care partners have been working to update beneficiary contact information for the inevitable return of redeterminations, and Medicaid managed care organizations can play a big role in raising awareness about the process, according to industry experts.

“I think that many members, probably 60% to 70% of folks, are just completely unaware that this is happening, and a lot of other folks just don’t realize the rigmarole they have to go through in order to maintain eligibility,” remarks Jerry Vitti, founder and CEO of Healthcare Financial, Inc., a firm that connects low-income, elderly, and disabled populations with Medicaid and other public benefit programs. “But plans can do mailings, do outreach, and be a connection point to Medicaid agencies where they can get enrolled.” Unfortunately, “they have uneven demographic information on these folks since the population is so transient, but they can reach out to members…and I think plans can do a really good job to build awareness of what’s happening and the implications.”

Health care transactions, particularly in the provider space, appear poised for another banner year, even as inflation, rising interest rates and a possible recession slow mergers & acquisitions (M&A) across the rest of the economy. Some providers are in financial crisis and seem sure to consolidate with each other or be taken over by private equity entities, while health insurers seem poised to spend pandemic-related windfalls.

Generally, health insurers are in good financial health. The health insurance business is somewhat protected from inflation, as carriers can pass through rising prices to commercial plan sponsors. Meanwhile, risk in government books of business is ultimately borne by the public. In addition, many carriers have plenty of cash on hand, meaning they are also insulated from rising interest rates. In spring 2020, when COVID-19 hospitalizations hit their first nationwide peak and local governments shuttered many businesses and in some cases barred nonessential medical procedures, health care utilization cratered. Utilization did not approach normal levels until the end of that year, and so premium revenues far outstripped claims paid for most insurers.

Both the specialty pharmacy market and the home infusion space continued to grow in 2022. Congress finally passed legislation that will allow Medicare to negotiate drug prices with manufacturers for the first time, and many of the impacted agents are expected to be specialty medications. As payers grappled with their drug costs, some implemented new utilization management strategies. And the COVID-19 pandemic, now approaching its fourth year, remained a disruptor in both the specialty pharmacy and home infusion markets. AIS Health, a division of MMIT, spoke with various industry experts on multiple 2022 issues impacting those industries.

While making their financial projections for 2023, health insurers have had to acknowledge that the timing of a major headwind — the resumption of Medicaid eligibility redeterminations — continued to be a question mark. Now, if a newly released draft of Congress’ year-end spending bill is passed as written, that uncertainty will be removed and replaced with a firm date: April 1.

Industry observers tell AIS Health, a division of MMIT, that it’s helpful for both state governments and managed care organizations to have a definite answer about when millions of people will start losing their Medicaid eligibility — although the event itself remains a net negative for MCOs.

An estimated 16 million working-age U.S. residents are afflicted with “long COVID,” but the risk factors and mechanisms of the condition — let alone how to treat it — are poorly understood, which means caring for patients with the disease is a daunting challenge for health plans. According to one health insurance leader, identifying members struggling with long COVID and proactively coordinating their care are crucial to contain costs and help members manage the disease.

Long COVID is a loose term for a condition with a variety of symptoms that persist after acute COVID-19 infection has passed. According to the National Institutes of Health (NIH), clinicians refer to the term as Post-acute Sequelae of SARS-CoV-2 Infection (PASC). Typical symptoms include fatigue, post-exertional malaise, shortness of breath, coughing, chest pain, heart palpitations, gastrointestinal issues, and joint and muscle pain, according to the Centers for Disease Control and Prevention. Medical researchers have yet to arrive at a consensus on the risk factors behind long COVID and have yet to develop a standard of care. For the most part, practitioners are just trying to manage symptoms as they come.

COVID-19 vaccines could add billions of dollars to overall health care spending each year if the federal government’s purchasing program ends early next year, according to a Kaiser Family Foundation analysis. To date, the federal government has spent about $25 billion on purchasing Pfizer and Moderna COVID-19 vaccines combined, at a weighted average purchase price of $20.69 per dose.

Pfizer and Moderna both announced that the average commercial price per dose for their vaccines could be three to four times greater than the price paid by the government, between $82 and $130 per dose. If half of U.S. adults receive a booster shot at the expected commercial prices, it could cost between $3.7 billion and $14.8 billion to purchase enough doses for the group (129 million).

COVID-19 vaccines are likely to cost payers billions on an annual basis, according to a new analysis based on publicly disclosed vaccine price projections by executives from Pfizer Inc. and Moderna Inc. Despite criticism from some progressive members of Congress, who say the vaccines will be priced too high, one vaccine expert tells AIS Health, a division of MMIT, that per-dose costs aren’t out of line with typical vaccine prices for adults.

The federal government initially bought COVID vaccines, using its purchasing power to accelerate research and development. COVID vaccines were developed in record time, and federal purchasing helped manufacturers hit remarkable earnings figures. However, despite requests from the Biden administration for more funds to purchase future COVID vaccines, Congress seems unlikely to pay for more. Federal vaccination funds and vaccine stockpiles are likely to run out sometime in 2023.

If the COVID-19 public health emergency (PHE) expires in April 2023, about 18 million Medicaid enrollees could lose their coverage over the following 14 months, an Urban Institute analysis projected. Among them, about 9.5 million people could transition to employer-sponsored insurance, 3.2 million could move to Children’s Health Insurance Program (CHIP) coverage, and 3.8 million could become uninsured. If the PHE were extended for an additional quarter, the number of people losing coverage could rise to nearly 19 million. The PHE is set to last at least through January, as the Biden administration is concerned about the potential of a winter wave of COVID infections.