The Top 6 Things that Pharmacies Need to Know About the Ending of the PHE

As the Public Health Emergency (PHE) ends we know you have questions. Fortunately, more answers are becoming available. Recently, CMS issued a document, Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency, that provides more details. To help you digest what’s inside, our pharmacy experts have selected some of the topics that are most important to pharmacies. You can access the complete CMS FAQ here.

Watch our latest video to hear from David Pope, our Chief Pharmacy Officer, about his perspective on the ending of the PHE.

1. When the PHE ends, will people insured by Medicare pay for COVID-19 vaccines?

• People with Medicare coverage will continue to have access to COVID-19 vaccinations without out-of-pocket costs after the end of the PHE.
• Once the federal government is no longer purchasing or distributing COVID-19 vaccines, people with Traditional Medicare pay nothing for a COVID-19 vaccination if their doctor or other qualified healthcare provider accepts assignment for giving the shot.
• People with Medicare Advantage (MA) plans should contact their plan for details about payment for COVID-19 vaccines, but MA beneficiaries will pay nothing for a COVID-19 vaccination if they receive their vaccinations from an in-network provider.

2. How much will CMS pay healthcare providers to administer COVID-19 vaccines through the end of the 2023 calendar year?

• Under the Medicare Part B preventive vaccine benefit, CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines through the end of the calendar year in which the Secretary ends the Emergency Use Authorization (EUA) declaration for drugs and biologicals with respect to COVID-19. The COVID-19 EUA declaration has not ended. (Note: The COVID-19 EUA declaration is distinct from, and not dependent on, the federal PHE for COVID-19, expected to expire on May 11, 2023, or the COVID-19 National Emergency that ended April 10, 2023).
• Effective January 1 of the year following the year in which the EUA declaration ends, CMS will set the payment rate for administering COVID-19 vaccines to align with the 3-payment rate for administering other Part B preventive vaccines, which is currently approximately $30 per dose. These payment rates do not apply in settings that are paid at reasonable cost for preventive vaccines and their administration (for example, Federally Qualified Health Centers and Rural Health Clinics). If someone is enrolled in an MA plan, the provider should submit claims for vaccine administration to the MA plan, and the amount the provider is paid for the vaccine administration service is determined by the contract between the MA plan and the provider if there is a contract. If there is no contract in place for COVID-19 vaccinations covered by the MA plan, the Medicare payment rate would apply.

3. How will Medicare cover diagnostic testing for COVID-19?

• People with Traditional Medicare can continue to receive COVID-19 PCR and antigen tests with no cost-sharing when the test is ordered by a physician or certain other healthcare providers, such as physician assistants and certain registered nurses, and performed by a laboratory.
• People enrolled in MA plans can continue to receive COVID-19 PCR and antigen tests when the test is covered by Medicare, but their cost-sharing may change when the COVID-19 PHE ends.
• Through the end of the COVID-19 PHE, Medicare covers and pays for over-the-counter (OTC) COVID-19 tests at no cost to people with Medicare Part B, including those with MA plans. The demonstration that allowed coverage and payment for OTC tests will end when the PHE ends on May 11; Medicare Advantage plans may continue to cover the tests, so check with your plan for details.

4. Can a pharmacy still perform COVID-19 testing and be paid by Medicare for it?

• A pharmacy that acquires a CLIA certificate (including, for example, a certificate of waiver) can enroll with Medicare as a clinical diagnostic laboratory to conduct and bill for clinical diagnostic laboratory tests authorized under their certificate, and many pharmacies have done this to furnish and bill for COVID-19 diagnostic laboratory tests during the PHE. This is permissible under current permanent Medicare policies.
• After the PHE ends, the test must be ordered by a physician or certain other health care providers, such as physician assistants and nurse practitioners.

5. What impact will the end of PHE have on private insurance coverage of vaccines?

• Most forms of private health insurance, including all Affordable Care Act-compliant plans, must continue to cover without cost-sharing COVID-19 vaccines furnished by an in-network health care provider. People with private health insurance may need to pay part of the cost if an out-of-network provider vaccinates them.

6. What impact will the end of the PHE have on private insurance coverage of COVID-19 diagnostic testing?

• Mandatory coverage for over-the-counter and laboratory-based COVID-19 PCR and antigen tests will end after the expected end of the PHE on May 11, 2023, though coverage will vary depending on the health plan. If private insurance chooses to cover these items or services, there may be cost sharing, prior authorization, or other forms of medical management may be required.

Stay tuned to our blog. As we receive more details about the ending of the PHE and what that means to your pharmacy and patients, we will share it here.