Concerns about youth mental health and well-being continue to increase, particularly in light of gun violence and the COVID-19 pandemic. Despite these mental health concerns, many children and adolescents face barriers in accessing behavioral health services (including mental health and/or substance use services). To address these challenges, recent legislation includes provisions to improve access to behavioral health services for youth. A number of these provisions involve expansions through Medicaid, including leveraging Medicaid to further build on school-based behavioral health services. Medicaid covers nearly four in ten children and adolescents nationwide, and provides significant financing for the delivery of behavioral health services through school-based programs.

To better understand the use of Medicaid in delivering and promoting of school-based behavioral health services, KFF surveyed state Medicaid officials about initiatives to promote access to Medicaid behavioral health services in school-based settings. These questions were part of KFF’s Behavioral Health Survey of state Medicaid programs, fielded as a supplement to the 22^nd annual budget survey of Medicaid officials conducted by KFF and Health Management Associates (HMA). A total of 44 states (including the District of Columbia) responded to the survey; of these, 41 states responded to the question about school-based care. In this analysis, we explore the strategies state Medicaid programs reported taking to promote and improve access to school-based behavioral health services, and how recent policies call on Medicaid to expand access to care for youth, particularly in schools.

Most schools offer behavioral health services to students and over time Medicaid has played a larger role in the delivery of these services. In the 2021-2022 school year, almost all (96%) public schools reported offering mental health services (although student utilization of offered services was unclear). These services are often supported through multiple sources of funding at the national, state, and local level. Over time, Medicaid has played a larger role in supporting these services and by 2014, nearly nine in ten school-based health centers (SBHCs) reported billing Medicaid. School-based behavioral health programs may rely on Medicaid in several ways, including reimbursement for medically necessary services that are part of a student’s Individualized Education Plan (IEP), for eligible health services for students with Medicaid coverage, and for some administrative activities. Additionally, since the 2014 reversal of the free care policy, the Centers for Medicare and Medicaid Services (CMS) has permitted payment of Medicaid services delivered to covered children, regardless of whether the school provides these services to all students without charge.

State Medicaid programs vary in how they promote access to Medicaid behavioral health services provided in schools. Although most schools provide mental health services, many report challenges in meeting the needs of all students, such as insufficient provider coverage and funding shortages. These challenges underscore the importance of addressing access issues in the school setting. KFF’s 2022 Behavioral Health survey asked Medicaid officials to report state initiatives to promote access to Medicaid behavioral health services provided in school-based settings. We found that states vary in their approaches – for example, some state Medicaid programs reported working more closely with local education agencies to help promote school-based behavioral health services (including Alabama, Massachusetts, Tennessee, and Vermont). Several states (including Arizona, Kentucky, Michigan, and Virginia) reported that they had or planned to take advantage of the reversal of the free care policy by expanding Medicaid reimbursement for school-based services provided to children without IEPs. A few states (including Oklahoma and the District of Columbia) are taking steps to incorporate crisis services for students. To incentivize providers, several states have also increased reimbursements for school-based providers (including Arizona, California, and South Carolina) – a strategy that many state Medicaid programs have adapted more broadly in order to attract Medicaid behavioral health professionals.

Below we highlight findings from several states that offer innovative and multipronged approaches to promoting access to Medicaid-based services.

• Arizona: Arizona has expanded its work with the local Department of Education to facilitate mental health and suicide prevention trainings in schools; and has taken steps to expand the number of school-based behavioral health providers. For example, the state Medicaid program has encouraged collaboration between schools and behavioral health outpatient providers interested in providing services at schools; and they incentivize behavioral health providers through enhanced payments. Additionally, Arizona’s Medicaid agency oversees administration of funds from the Children’s Behavioral Health Services Fund, which provides a pathway for students who are underinsured or uninsured to receive behavioral health services from providers contracted with Arizona’s Medicaid program.
• California: California’s recent state-wide Children and Youth Behavioral Health Initiative is a multistep approach to expanding access to youth behavioral health care. One focus of this initiative allows for managed care plans to earn incentive payments for implementing interventions that increase access to school-based behavioral health services (further outlined in the Student Behavioral Health Incentive Program). Higher incentive payments may be offered for interventions that increase reimbursement rates, serve vulnerable youth populations, and/or reduce inequities. Further, California will develop statewide all-payer fee schedules for school-based behavioral health services with the intention of streamlining the reimbursement process; and will develop a statewide network of school-based behavioral health counselors..
• South Carolina: Beginning in 2022, South Carolina modified its school-based behavioral health policy to give districts more options for delivery of behavioral health services in their schools. Previously, school districts were only able to provide behavioral health services through the Department of Mental Health (DMH). However, districts will now be able to either contract with DMH, hire their own counselors, and/or contract with private providers. With each option, school districts can bill the state’s Medicaid program. Additionally, through this initiative, an alternative fee schedule was developed in order to ensure that schools have sufficient provider capacity.

Some school-based programs have long provided behavioral health services through telehealth, even before the pandemic. In our survey, a few states reported plans to expand these remote services in unique ways, including creating a hub location away from school grounds that is staffed with behavioral health providers. Students could then access these providers remotely from their schools or travel to the hub location for in-person services. While this model may expand access to students overall by increasing telehealth services, if telehealth replaces existing in-person behavioral health services, some students may experience disruptions in care. In general, during the COVID-19 pandemic states have taken advantage of broad authority to expand Medicaid telehealth policies, resulting in high telehealth utilization across populations.

Looking Ahead

Recognizing Medicaid’s importance in covering and financing behavioral health care for children, recent legislation utilizes Medicaid as one pathway to expand school-based behavioral health services. The Bipartisan Safer Communities Act signed into law in June 2022 included a requirement for CMS to provide updated guidance on how to support and expand school-based behavioral health services, and also allocated $50 million in planning grants for states. In August 2022, CMS released its first guidance outlining state flexibilities and strategies for expanding Medicaid-covered behavioral health services in schools. Additionally, CMS indicated it intends to release further guidance, including an updated claiming guide and technical assistance guide. This guidance is expected to provide best practices for paying for school-based services, provide strategies for reducing administrative burdens, and supply examples of providers who can provide school-based Medicaid services.

More recently, the Consolidated Appropriations Act (CAA) passed in December 2022 includes Medicaid provisions that may promote access to behavioral health and other care for children, such as a requirement for states to implement 12 months of continuous eligibility for children in Medicaid and CHIP and a requirement for CMS to issue guidance and provide technical support to expand crisis services.  The CAA also requires state Medicaid and CHIP programs to maintain updated provider network directories that include behavioral health providers participating in Medicaid and information on whether they are accepting new patients and on language and cultural competencies, among others. Current directories are often outdated and may contribute to barriers to care. In addition to expanding access through Medicaid, the CAA includes other provisions focused on youth behavioral health support. For example, additional funding was allocated for Project AWARE, which provides trauma-based support for youth.

These recent changes at the federal level combined with state-level Medicaid efforts to streamline and promote access to services further highlight the increased attention on youth mental health and substance use concerns. Moreover, in his State of the Union address, President Biden spotlighted continued efforts to improve school-based mental health services, including how Medicaid can be used. Moving forward, steps to address workforce shortages and increases in behavioral health care via telehealth may also help mitigate access to care issues for youth mental health.

Executive Summary

At the start of the pandemic, Congress enacted the Families First Coronavirus Response Act (FFCRA), which included a requirement that Medicaid programs keep people continuously enrolled through the end of the COVID-19 public health emergency (PHE) in exchange for enhanced federal funding. Primarily due to the continuous enrollment provision, Medicaid enrollment has grown substantially compared to before the pandemic. When the continuous enrollment provision ends, millions of people could lose coverage if they are no longer eligible or face administrative barriers during redeterminations despite remaining eligible. The Consolidated Appropriations Act, 2023 de-links the Medicaid continuous enrollment provision from the PHE allowing states to resume disenrollments starting April 1, 2023. States can work with Medicaid managed care organizations (MCOs), which deliver care to more than two-thirds of all Medicaid beneficiaries nationally, to conduct outreach to enrollees to prepare them for the end of the continuous enrollment period. CMS has issued specific guidance allowing states to permit MCOs to update enrollee contact information and conduct outreach about the eligibility renewal process to facilitate continued enrollment as well as Marketplace transitions, where appropriate.

To better understand the role Medicaid MCOs may play in unwinding the continuous enrollment provision, KFF, in collaboration with the Association for Community Affiliated Plans (ACAP), fielded a short survey of Medicaid MCOs (also referred to as managed care plans throughout) in October-November 2022. ACAP member plans are not-for-profit safety net health plans that serve more than 20 million Medicaid enrollees, or about one in five Medicaid enrollees. The survey was fielded among all ACAP health plans that participate in the Medicaid market. A total of 29 plans (of 65), accounting for over 13.2 million Medicaid beneficiaries enrolled in Medicaid MCOs as of September 2022, across 15 states¹  (of 26) responded to the survey. To gain additional insights, a roundtable discussion was held in mid-November 2022 with representatives from 10 plans. While ACAP member plans may differ in important ways from for-profit plans (which enroll more than 50% of all Medicaid beneficiaries nationally), all plans are going to want to maintain enrollment and revenue to the extent possible, and results provide important insights into implications and challenges of unwinding. For additional details, see the Methods section at the end of this brief. Key findings include the following:

Updating beneficiary contact information. Only about one-third of responding plans reported having verified/current contact information for between 76% to 100% of their Medicaid members. Most responding plans reported they are taking action to reach out to members directly to assist with updating contact information and many are working with third parties (e.g., providers, community-based organizations (CBOs), subcontractors/vendors etc.). Nearly all responding plans said that reaching Medicaid beneficiaries is a challenge. Plans also described challenges involved with transferring updated contact information data to the state.

Renewal Outreach. Nearly all responding plans reported the state where they operate is planning to provide monthly files containing information on members for whom the state is initiating the renewal process, and more than half reported that they expect to receive monthly files with information on members that have not submitted renewal information and are at risk of losing coverage. Only one in five responding plans reported hiring (or planning to hire) additional staff to help with renewal efforts. About half of responding plans indicated their renewal outreach strategy includes targeted outreach for specific populations (e.g., pregnant, or postpartum individuals, individuals with chronic conditions, individuals with mental illness or substance use disorder (SUD)).

Coverage Transitions. More than half of responding plans reported that their state Medicaid agency is planning to provide periodic termination files so plans can conduct outreach to individuals terminated for procedural reasons. However, several plans indicated termination files received from the state do not include the reason a beneficiary may be losing coverage. Plans stressed that without this information their ability to conduct targeted outreach is constrained. Nearly all responding plans that also offer a Qualified Health Plan (QHP) in the Affordable Care Act (ACA) marketplace reported that the state will permit the plan to share information about their QHP with enrollees found ineligible for Medicaid. The expectation is that many people no longer eligible for Medicaid because their incomes have risen will be eligible for premium assistance under the ACA.

Unwinding implications. Three-quarters of responding plans reported expecting between 10% to 25% of their enrollees to lose Medicaid coverage over the unwinding period. Responding plans most frequently reported decline in Medicaid enrollment, loss in revenue, churn, and disruptions in member care as significant challenges they expect related to unwinding. Most responding plans expect the risk profile (or acuity) of members to increase, as plans anticipate “stayers” will be sicker than “leavers” and expect medical loss ratios (MLRs) – the share of premiums going to pay for care – to increase.

With a date certain for the end of the continuous enrollment provision, states are finalizing unwinding operational plans and prioritization approaches as well as readying systems. Plans highlighted strategies that could help address unwinding challenges including strengthening communication across state and county agencies, providers, community-based organizations (CBOs), and health insurance Marketplaces; providing detailed, timely data transfers to enable plans to conduct targeted outreach; increasing automatic (“ex parte”) renewals; maximizing lead time for plans to conduct outreach to members before terminating coverage; state consideration of adopting continuous eligibility policies, and improving alignment of eligibility requirements and processes across programs/eligibility pathways.

Findings

Updating Beneficiary Contact Information

To help ensure eligible enrollees retain coverage, states may direct MCOs to seek updated contact information from enrollees. If plans contract with a third party to collect this information, they must confirm the accuracy of updates with enrollees directly. MCOs may share this information with the state or assist individuals in providing their updated contact information to the state. States may accept updated enrollee contact information from MCOs including mailing addresses, telephone numbers, and email addresses provided the state complies with certain beneficiary notice requirements (to confirm the accuracy of updated contact information) or the state receives a waiver of such requirements from CMS.

Only about one-third of responding plans reported having verified/current contact information for between 76% to 100% of their Medicaid members (Figure 1). As background, plans were asked to identify the share of Medicaid members for which they currently have verified contact information. This information is essential to ensuring members receive renewal notices and other communication from the state and the plan. Plans were also asked how often member mailing address, phone number, and email information received from the state is accurate. Less than half of responding plans (38%) reported member information received from the state Medicaid agency is accurate “most of the time” (Figure 1). During the roundtable, several plans discussed the need to maintain “shadow files” to retain up-to-date member contact information, as periodic data feeds from the state may override their member data. Plan staff also reported variable success in transferring updated data to the state (discussed in more detail below).

Most plans reported they are taking action to reach out to members directly to assist with updating contact information. Plans reported conducting direct member outreach via text, email, phone, robocall, interactive voice response (IVR), and letter/postcard. Several plans noted they verify contact information on every inbound and outbound call. In addition to conducting direct member outreach, plans also reported mass messaging via social media, website, member newsletter, tv/radio segments, and other marketing/advertisements. Plans may assist Medicaid members with updating their contact information with the state (or county) Medicaid agency or may obtain updated contact information to share with the state directly. Generally, plans reported live calls and text messaging have been the most effective methods to obtain and update contact information.

Nearly all responding plans reported reaching Medicaid beneficiaries poses a challenge to updating member contact information (Figure 2). In particular, restrictions on text messaging imposed by the Telephone Consumer Protection Act (TCPA) or state rules were cited as a challenge by about half of responding plans. TCPA prohibits sending automated text messages without obtaining the recipient's prior consent. While prior Federal Communications Commission (FCC) rulings confirmed federal and state governments are not subject to TCPA restrictions, CMS had been working to clarify with the FCC whether contractors of state agencies (including MCOs) are subject to the TCPA. On January 23, 2023, the FCC provided guidance to federal and state agencies, as well as their partners (including managed care entities), enabling them to make autodialed (and prerecorded) text and voice calls to raise awareness about Medicaid eligibility and enrollment requirements without violating the TCPA. Other challenges identified by plans include difficulty obtaining documentation from beneficiaries to assist with updating information; lack of communication between state Medicaid agency and Medicaid beneficiaries during the PHE leading to more outdated member information; and difficulty obtaining member approval/confirmation for updates received from third parties.

The majority of plans reported working with third parties to help obtain updated member contact information and to support outreach and communication efforts. Plans said they are partnering with different entities including providers, community-based organizations (CBOs), other state and local agencies (e.g., social services, public health, schools), and subcontractors and vendors (e.g., transportation vendors, pharmacy benefit managers (PBMs), contractors engaged specifically to do outreach/help members during the unwinding process) to ensure member contact information is up-to-date. A few plans described efforts to implement “feeds” for updated addresses or to flag instances of mismatched data with pharmacy or transportation vendors. One plan reported all competitor health plans in the market came together and developed a rack card which includes contact information/branding for each health plan, brief messaging around ensuring Medicaid member addresses are up-to-date, and a QR code enabling members to easily update their address. Their goal is to deliver these cards to hospitals, providers, behavioral health agencies, social service community agencies, schools, and pharmacies across the state. Plans also reported a variety of efforts to educate and engage providers and CBOs about the upcoming end of the continuous enrollment period (e.g., developing provider toolkits and training) and to support provider and CBO outreach and communication efforts (e.g., hosting renewal/recertification events with providers and CBOs and other co-branded strategies).

Nearly three in four responding plans reported providing updated member contact information data to the state or county Medicaid agency on a weekly, bi-weekly, or monthly basis, although plans also identified challenges that undermine efforts to share this information. In a number of states, counties administer the Medicaid program; notably, plans operating in California reported data is exchanged with county agencies instead of directly with the state Medicaid agency. Plans described a variety of challenges involved with transferring updated data including building systems/processes to allow for data exchange; lack of confirmation from the state agency that updated contact information was received and action was taken; lag in time for state systems to update member records; and subsequent state data runs that do not reflect updated data supplied by plan. Plans from a few states reported the state is currently unable to receive updated contact information from the plan.

Renewal Outreach

Nearly three-quarters of responding plans reported conducting outreach about Medicaid renewals prior to the COVID-19 pandemic. As background, plans were asked whether they communicated with enrollees about renewals prior to the pandemic. Pre-pandemic outreach reported by plans ranged from sending member reminders (mailings, phone calls etc.) to more active renewal application assistance as well as engagement with community partners.

Nearly all responding plans said their state is planning to provide monthly files containing information on members for whom the state is initiating the renewal process. Additionally, more than half of responding plans reported they expect the state Medicaid agency to provide monthly files with information on members that have yet to submit renewal forms or additional documentation and are at risk of losing coverage. CMS guidance emphasizes federal Medicaid managed care marketing rules (42 CFR 438.104) do not prohibit plans from providing information and conducting general outreach about the eligibility renewal process on behalf of states. To enable plans to conduct targeted outreach and provide assistance with the renewal process, CMS has encouraged states to share information with plans including beneficiaries due for renewal and those at risk of losing coverage who have yet to submit renewal forms or other documentation.

Only one in five responding plans reported hiring (or planning to hire) additional staff to help with renewal efforts.  Even without new staff, plans reported planning multiple outreach efforts. Nearly three-quarters of responding plans said they will disseminate outreach materials developed by the state Medicaid agency about the need to renew coverage and will also develop other outreach materials to communicate with Medicaid members. All responding plans reported outreach materials will be available in multiple languages, most commonly Spanish. About three-quarters of responding plans reported using social media to conduct outreach. Some plans indicated they will be developing text messaging campaigns around renewals and others noted they will call members whose renewals are due. Plans also said they were developing provider toolkits specifically focused on renewals that, in some cases, include videos providers can show in their waiting rooms.

About half of responding plans reported their renewal outreach strategy includes targeted outreach for specific populations (Figure 3), most frequently for individuals with chronic conditions, pregnant individuals, postpartum individuals, and individuals with mental illness or substance use disorder. Plans indicated these targeted outreach strategies would include additional communication; customized messaging; call center and provider portal alerts for select members; leveraging care managers, transition teams, and life coaches; and partnering with CBOs to provide in-home application assistance for members with disabilities and homebound members.

Coverage Transitions

More than half of responding plans reported that the state Medicaid agency is planning to provide periodic termination files; however, outreach may be difficult if files do not include the reason for termination. Most plans reported expecting to receive termination files monthly. Medicaid managed care marketing rules at 42 CFR 438.104 do not prohibit general outreach from Medicaid managed care plans for eligibility purposes; a plan’s ability to conduct this activity depends on the plan’s contract with the state agency. CMS also clarified in recent guidance that federal marketing rules do not differentiate between coverage termination reasons and states may use plans to conduct general eligibility outreach (on behalf of the state) for any potential coverage termination reason. However, several plans indicated termination files often do not include the reason a beneficiary may be losing coverage. Plans stressed that without this information, their ability to conduct targeted outreach is constrained.

Nearly all responding plans that also offer a QHP reported that the state will permit the plan to share information about their QHP with enrollees found ineligible for Medicaid. CMS guidance outlines states may encourage MCOs that also offer a QHP in the ACA Marketplace to share information with their own enrollees who have been determined ineligible for Medicaid to assist in the transfer of individuals to Marketplace coverage (which has higher income eligibility thresholds than Medicaid). To avoid gaps in coverage, managed care plans may reach out to individuals before they lose coverage to allow them to apply for Marketplace coverage in advance. Even though CMS indicates this activity is allowable under federal rules, plans must comply with state-specific laws and/or contract requirements that may prohibit this activity. During the roundtable, a few plans highlighted the significance of being able to direct ineligible members to affiliated Marketplace plans which was not standard protocol previously. Plans will outreach in a variety of ways (e.g., disseminating written materials) and affiliated QHP plans are also planning to do direct outreach as well.

Implications and Challenges

Three-quarters of responding plans reported they expect between 10% to 25% of their enrollees to lose Medicaid coverage over the unwinding period (Figure 4). While the number of Medicaid enrollees who may be disenrolled during the unwinding period is highly uncertain, it is estimated that millions will lose coverage. The share of individuals disenrolled across states will vary due to differences in how states prioritize and process renewals. One-quarter of responding plans reported they expect that among enrollees who lose coverage, 26% or more will lose coverage for procedural reasons (i.e., related to missing or incomplete information) versus being determined ineligible (Figure 4).  Only a small share of responding plans participate as a QHP in the health insurance Marketplace (9 plans), but these plans reported they expect to only enroll a small share of individuals into their QHP offering following Medicaid disenrollment during unwinding (data not shown).

Responding plans most frequently reported decline in Medicaid enrollment and related revenue loss, enrollee churn, and disruptions in member care as significant challenges they are expecting related to unwinding (Figure 5). Prior to the pandemic, managed care plans long cited lack of continuous eligibility, or churn, as a key challenge in ensuring access to care and care continuity for members. During the roundtable, plans expressed concern about members with chronic conditions and the significant impact of interrupted coverage on access to needed services (e.g., loss of access to HIV, behavioral health, hypertension, or diabetes care). On the survey, plans were also asked to discuss the anticipated effects of the end of the continuous enrollment provision on service utilization, enrollee composition, and plan medical loss ratio (MLR). Most responding plans expect the risk profile (or acuity) of members to increase, as plans anticipate “stayers” will be sicker than “leavers.” Plans also expect MLRs to increase (the MLR reflects the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement, with the remainder going to administrative costs and profits).

Looking Ahead

During the unwinding, millions of people could lose coverage if they are no longer eligible or face administrative barriers to renewing coverage despite remaining eligible. The significant volume of work that states face will place a heavy burden on eligibility and enrollment staff and could contribute to disenrollments due to procedural reasons. Medicaid managed care plans may be well positioned to assist states in conducting outreach and providing support to enrollees who will need to navigate the renewal process. With a date certain for the end of the continuous enrollment provision, states are finalizing unwinding operational plans and prioritization approaches as well as readying systems. Plans highlighted strategies that could help address unwinding challenges including strengthening communication across state and county agencies, providers, CBOs, and health insurance Marketplaces; providing detailed, timely data transfers to enable plans to conduct targeted outreach; increasing automatic (“ex parte”) renewals; maximizing lead time for plans to conduct outreach to members before terminating coverage; and state consideration of adopting continuous eligibility policies, and improving alignment of eligibility requirements and processes across programs programs/eligibility pathways.

Methods

To better understand the role of Medicaid MCOs in unwinding, KFF fielded a short Medicaid managed care plan survey in October 2022 in collaboration with the Association for Community Affiliated Plans (ACAP). ACAP member plans are not-for-profit safety net health plans which serve more than 20 million Medicaid enrollees, or about one in five Medicaid enrollees. While ACAP member plans may differ in important ways from for-profit plans (which enroll more than 50% of all Medicaid beneficiaries nationally), results provide important insights into implications and challenges of unwinding. The survey was fielded among all ACAP health plans that participate in the Medicaid market as of October 2022 (65 plans across 26 states). A total of 29 plans accounting for over 13.2 million Medicaid beneficiaries enrolled in comprehensive MCOs as of September 2022 across 15 states (AZ, CA, IL, IN, MA, MD, MN, NY, OH, OR, PA, RI, TX, WA, and WI) responded to the survey. Responding plan enrollment ranged from approximately 3,600 to 2.5 million with median enrollment of approximately 310,000. Nine plans that participated in the survey reported their health plan also participates as a qualified health plan (QHP) in the health insurance Marketplace. Staff from 10 plans across 9 states (AZ, CA, IL, MN, NY, OH, PA, TX, and WA) participated in a roundtable discussion held on November 16, 2022.

1. AZ, CA, IL, IN, MA, MD, MN, NY, OH, OR, PA, RI, TX, WA, WI ↩︎

February 1^st marked the beginning of Black History Month. The 2023 theme for Black History Month is Black Resistance, an exploration of how African Americans have nurtured and protected Black lives, and fought against historic and current racial inequality. In fact, while Black people have made great contributions and achievements in the United States, they continue to face many health and health care disparities that adversely impact their overall health and well-being. These disparities have been exacerbated by the uneven impacts of the COVID-pandemic, ongoing racism and discrimination, and police violence against and killings of Black people. Moreover, the long history of inequitable health outcomes among Black people reflects the abuses faced during slavery, segregation, mass incarceration and their persistent legacies.

Black people make up 12% of the population in the United State as of 2021 (Figure 1). The Black population has grown has grown by nearly 30% since 2000, with the increase in foreign born Black people playing a significant role in this growth. As the population has grown, it has become more diverse, with an increase in the share of Black people who identify as multiracial and/or Hispanic.

Black people face increased barriers to accessing and utilizing health care. Black people are more likely to report financial barriers to receiving health care (Figure 2). While the implementation of the Affordable Care Act and pandemic-era policies have helped narrow some disparities in health coverage, nonelderly Black people (11%) continue to have a higher uninsured rate than their White peers (7%) (Figure 3). Further, compared to White people, Black people are more likely to face social and economic challenges that adversely impact health, including higher rates of poverty and food insecurity (Figure 4). Black adults are also more likely than White adults and to report being treated unfairly because of their race/ethnicity while seeking care for themselves or family members (Figure 5).

Reflecting these inequities, Black people report having worse health outcomes compared to White people. At birth, Black people have shorter life expectancies compared to White people (70.8 vs. 76.4 years), and they experienced a larger decline in life expectancy than White people between 2019 and 2021, with it falling by 4.0 years. (Figure 6). Black people have the highest rates of infant mortality (Figure 7) and maternal mortality (Figure 8) across all racial and ethnic groups for which data were available and experienced the largest increase in maternal mortality when compared to pre-pandemic levels (Figure 8). Although Black people fare better than White people for some cancer screening and cancer incidence measures, they have higher rates of cancer mortality (Figure 9). The underlying inequities in health and health care for Black people also contributed to disparities in COVID-19, with Black people facing a higher risk of hospitalization and death due to COVID-19 compared with White people. Moreover, the disparate effects of COVID-19 may lead to widening disparities in health going forward.

Ongoing racism and discrimination, police violence against and killings of Black people, and gun violence also negatively impact health and well-being of Black people. Black people’s repeated and chronic exposure to stressors associated with racism and discrimination drive rapid biological aging and poorer health outcomes. Black people are more than three times as likely to be killed by police than White people, and over the course of a lifetime 1 in every 1,000 Black men can expect to be killed by the police. This exposure to police violence has been found to have negative mental health outcomes for Black people. Black youth have also been disproportionately affected by gun violence, which can adversely affect the mental health and well-being of children. Data show that firearm death rates sharply increased among Black youth during the pandemic, largely due to gun assaults and suicides by firearm (Figure 10). While overall rates of mental illness and substance use disorder are lower for Black people compared to White people, they may be underdiagnosed among people of color. Data also point to increasing mental health needs as Black people have experienced a faster rise in deaths by suicide and drug overdose deaths compared to White people (Figures 11 and 12). These findings highlight the importance of addressing mental health needs among the Black population and reducing barriers to treatment.

In line with this year’s Black History Month theme, resisting health inequities by addressing the historic and current health and social challenges faced by Black people will be key to achieving health equity. As the Black population continues to grow and become more diverse, improving their overall health and well-being will support the overall health and prosperity of the United States.

Since 2021, federal law has required hospitals to publicly post information about their standard prices and negotiated discount rates for common health services to encourage consumers to compare prices and to promote competition.

To date, however, the transparency data currently shared by hospitals to comply with the law are messy, inconsistent and confusing, making it challenging, if not impossible, for patients or researchers to use them to compare prices across hospitals or payers, a new KFF analysis finds.

Shortcomings in the available data include:

• There are inconsistencies in how the data connect specific services with prices, especially for episodes of care that may combine multiple items into one charge, making comparisons difficult.

• The quality of the data varies widely, including some instances with excessively low or high values for negotiated rates that likely stem from errors. For instance, for hip and knee replacements, the data suggest some hospitals’ prices are under $1,000 while others are more than $1 million.
• Crucial pieces of information for interpreting the applicability of price are missing, such as contracting method and the payer class (i.e. Medicare, Medicaid and commercial).

Drawing on hospital price transparency data compiled by Turquoise Health, the analysis provides several examples that illustrate the difficulty in drawing meaningful conclusions from available data about the prices for specific services at different hospitals or for different payers.

Many of these shortcomings stem from a lack of specificity and standardization in the requirements for what hospitals must report and how they report it. To address these challenges, federal regulators have suggested specific ways for hospitals to format and validate their data, but hospitals are not required to follow that guidance.

The analysis, Ongoing Challenges with Hospital Price Transparency, is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

Since 2021, federal law has required hospitals to publicly post information about their standard prices and negotiated discount rates for common health services to encourage consumers to compare prices and to promote competition.

This analysis examines transparency data currently shared by hospitals to comply with the law and finds that they are messy, inconsistent and confusing, making it challenging, if not impossible, for patients or researchers to use them for their intended purpose. Drawing on hospital price transparency data compiled by Turquoise Health, the analysis includes examples that illustrate the difficulty in drawing meaningful conclusions from available data.

Many of these shortcomings stem from a lack of specificity and standardization in the requirements for what hospitals must report and how they report it. To address these challenges, federal regulators have suggested specific ways for hospitals to format and validate their data, but hospitals are not required to follow that guidance.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub that monitors and assesses the performance of the U.S. health system.

See KFF’s analysis of more recent data in Claims Denials and Appeals in ACA Marketplace Plans in 2023, published in January 2025.

In this brief, we analyze transparency data released by the Centers for Medicare and Medicaid Services (CMS) on claims denials and appeals for non-group qualified health plans (QHPs) offered on HealthCare.gov. Data were reported by insurers for the 2021 plan year and posted in a public use file in October 2022. We find that, across HealthCare.gov insurers with complete data, nearly 17% of in-network claims were denied in 2021. Insurer denial rates varied widely around this average, ranging from 2% to 49%.

CMS requires insurers to report the reasons for claims denials at the plan level. Of in-network claims, about 14% were denied because the claim was for an excluded service, 8% due to lack of preauthorization or referral, and only about 2% based on medical necessity. Most plan-reported denials (77%) were classified as ‘all other reasons.’

As in our previous analysis of claims denials, we find that consumers rarely appeal denied claims and when they do, insurers usually uphold their original decision. In 2021, HealthCare.gov consumers appealed less than two-tenths of 1% of denied in-network claims, and insurers upheld most (59%) denials on appeal.

The Affordable Care Act (ACA) requires transparency data reporting by all non-grandfathered employer-sponsored health plans and by non-group plans sold on and off the marketplace. Data are to inform regulators and consumers about how health plans work in practice. For example, transparency data could be helpful in oversight of compliance with the Mental Health Parity and Addiction Equity Act (MHPAEA), revealing how or whether claims denial rates differ for behavioral health vs other services. It could also make more transparent trends in the incidence and handling of claims for surprise medical bills, now protected under the No Surprises Act. Yet, the federal government’s broad authority to require transparency data reporting has not been fully implemented. Data to answer these questions are not collected; and data that are collected are not audited, for example, to ensure issuers report data consistently. Transparency data also are not used in oversight nor to develop other tools or indicators to help consumers see and compare differences across plans.

ACA Transparency Data

Under the ACA, required reporting fields for transparency-in-coverage data include:

• Claims payment policies and practices
• Periodic financial disclosures
• Data on enrollment
• Data on disenrollment
• Data on the number of claims that are denied
• Data on rating practices
• Information on cost-sharing and payments with respect to any out-of-network coverage
• Information on enrollee and participant rights under this title
• Other information as determined appropriate by the Secretary

The law requires data to be available to state insurance regulators and to the public.

Partial implementation of ACA transparency data reporting began with the 2015 plan year. To date, reporting is required only by issuers for their qualified health plans (QHP) offered on HealthCare.gov. Issuers report only on the number of in-network claims submitted and denied, the number of such denials that are appealed, and the outcome of appeals. Aggregate data are reported at the issuer level. In 2022, issuers reported aggregated data on all HealthCare.gov QHPs they offered in 2021. Since 2018, issuers are also required to report data at the health plan level, including certain reasons for claims denials. Issuers only report plan-level transparency data plans they seek to offer on HealthCare.gov in the coming year. As a result, for any given issuer, the total plan-level claims reported may not equal the issuer-level claims reported for the 2021 coverage year.¹  CMS does not collect data on all fields enumerated in the ACA, including out-of-network claims submitted and out-of-network enrollee cost sharing and payments. Nor has it required any further detailed reporting (e.g., on claims or appeals by type of service or diagnosis.) Federal agencies have yet to require transparency in coverage data reporting by other non-group plans or employer-sponsored plans.² 

Claims Denials and Appeals in 2021

This brief focuses on transparency data for the 2021 calendar year submitted by qualified health plans (QHPs) offered to individuals on HealthCare.gov as part of the 2023 plan certification process. Our analysis excludes stand-alone dental plans and issuers with incomplete data or less than 1,000 claims submitted. From the public use file, we developed a working file that is posted with this brief.

Claims submitted and denied

Of the 230 major medical issuers in HealthCare.gov states that reported for the 2021 plan year, 162 reported receiving at least 1,000 in-network claims and show data on claims received and denied. Together these issuers reported 291.6 million in-network claims received, of which 48.3 million were denied, for an average in-network claims denial rate of 16.6% (Figure 1)

Issuer denial rates for in-network claims ranged from 2% to 49%. In 2021, 41 of the 162 reporting issuers had a denial rate of less than 10%, 65 issuers denied between 10% and 19% of in-network claims, 39 issuers denied 20-29%, and 17 issuers denied 30% or more of in-network claims. (Figure 2) Issuers that report denying one-third or more of all in-network claims in 2021 included Meridian Health Plan of Michigan, Absolute Total Care in South Carolina, Celtic Insurance in 7 states (FL, IL, IN, MO, NH, TN, TX), Ambetter Insurance in 3 states (GA, MS, NC), Optimum Choice in Virginia, Buckeye Community Health Plan in Ohio, Health Net of Arizona, and UnitedHealthcare of Arizona.

Table 1 shows denial rates for issuers who reported the highest volume of in-network claims in 2021, receiving over 5 million claims. Among these issuers, denial rates ranged from 5.7%. to 41.9%.

Denial rates also varied geographically. (Figure 3) State average denial rates can obscure variation within a state. For example, in Florida, where the average denial rate was 13% in 2021, the five issuers with largest market shares reported denial rates for in-network claims ranging from 15% to 42%.

Plan-level claims denial data

CMS also collects limited transparency data at the plan level. Of the 162 issuers reporting aggregate data, 158 report plan level data on in-network claims received and denied, as well as data on selected reasons for denials. Denial rates varied somewhat based on plan metal levels. On average, in 2021, HealthCare.gov issuers denied 15.9% of in-network claims in their bronze plans, 17.3% in silver plans, 17.1% in gold plans, 11.4% in platinum plans, and 19.7% in catastrophic plans.

Why do health plans deny claims?

HealthCare.gov plans also report on certain categories of reasons for in-network claims denials:

• Denials due to lack of prior authorization or referral
• Denials due to an out-of-network provider
• Denials due to an exclusion of a service
• Denials based on medical necessity (reported separately for behavioral health and other services)
• Denials for all other reasons

A claim might be denied for more than one reason. In addition, insurers are required to report reasons for denials of claims that ultimately are paid. In all, insurers reported 41.7 million denied in-network claims at the plan level for the 2021 coverage year. Insurers also reported 44.7 million reasons for denying in-network claims, including roughly 3 million denials of claims that were later paid.

The distribution of in-network denials by reason is shown in Table 2. (We set aside data for out-of-network claim denials because CMS does not require issuers to report on the number of out-of-network claims received.) About 8% of these 44.7 million denials were for services that lacked prior-authorization or referral, 13.5% were for excluded services, 1.7% for medical necessity reasons, and 76.5% for all other reasons.

Again, totals obscure variation by plan. For example, while about 2% of all in-network claim denials by HealthCare.gov plans were based on medical necessity, several plans with large volume of denials (more than 75,000) reported much higher shares for medical necessity reasons, up to 37%. (Table 3)

Similarly, while about 9% of all in-network denials by HealthCare.gov plans were based on lack of prior-authorization or referral, some plans reported a much larger share of their denials were for that reason – as high as 24%. (Table 4)

The transparency data indicate that plans seem to apply utilization review techniques very differently. However, without more detail on the types of claims subject to these denials, it is not possible to discern what the implications for patients might be.

Of note, Connecticut regulators require health insurers in all market segments, including fully insured employer plans, to report annual data on claims payment practices, and other measures. Denial rates and reasons reported by Connecticut insurers are similar to those reported by HealthCare.gov QHPs. (Table 5)

Appeals

ACA transparency data show the number of denied in-network claims that consumers appealed to the plan (internal appeals) and the number of denials overturned at internal appeal. Consumers whose denial is upheld at internal appeal sometimes have the right to an independent external appeal. (Under federal regulations, eligibility for external appeal is generally restricted to medical necessity denials, though in some states all denials can be externally appealed.) HealthCare.gov issuers also report the number of external appeals made by consumers, and the number of externally appealed denials that were overturned. The CMS public use file suppresses values lower than 10.

Consumers rarely appeal denied claims. Of the more than 48 million in-network denied claims in 2021, marketplace enrollees appealed 90,599 – an appeal rate of less than two-tenths of one percent. (Figure 4) Issuers upheld 59% of denials that were appealed.

Marketplace consumers also rarely file external appeals. From ACA transparency data (and imputing a value of “5” for each cell where values were suppressed) we estimate just over 2,500 external appeals were filed by marketplace enrollees in 2021.

Discussion

Limited ACA transparency data collected by the federal government continues to show wide disparities in the rate at which marketplace plans pay claims. While on average HealthCare.gov insurers denied nearly 17% of in-network claims in 2021, some insurers report denying nearly half of in-network claims submitted. The federal government has not expanded or revised transparency data reporting requirements in years and does not appear to conduct any oversight using data that are reported by marketplace plans. As a result, consumers are not provided any information about how reliably marketplace plan options pay claims and plans reporting high claims denial rates do not appear to face any consequences.

1. If an issuer offered a plan in 2021 that it no longer intends to offer in 2023, it should report issuer-level data for that 2021 plan, but no plan-level 2021 data will be reported for that plan. Similarly, if an issuer seeks to offer a plan in 2023 that it did not offer in 2021, it will report transparency data of “NA” for that plan in 2022.  Under these reporting rules, the total issuer-level claims data for 2021 may include plans that will not be offered in 2023; as a result the plan-level claims total may not equal the issuer-level claims total.  For more detailed transparency data reporting instructions, see “Qualified Health Plan Issuer Application Instructions, Plan Year 2023” starting at page 2E-1. ↩︎
2. In 2020, the Trump Administration issued a final regulation requiring all non-grandfathered plans – including those sponsored by employers or offered by issuers outside of HealthCare.gov – to report billed charges and negotiated allowed amounts for covered items and services, enforceable beginning July 1, 2022. The regulation invokes ACA transparency data reporting authority but does not require plans to report prices to CMS; instead, price data must be posted online by each plan sponsor and issuer, making it unlikely that the price data across plans and issuers will be compiled into a single public use file provided by the federal government. ↩︎

On January 26, the Centers for Medicare and Medicaid Services (CMS) approved California’s Section 1115 request to cover a package of reentry services for certain groups of incarcerated individuals 90 days prior to release. This approval is the first to include a partial waiver of the statutory Medicaid inmate exclusion policy, which prohibits Medicaid from paying for services provided during incarceration (except for inpatient services). Justice-involved individuals are disproportionately low-income and often have complex and/or chronic conditions, including behavioral health needs (mental health conditions and/or substance use disorder (SUD)). Reentry services aim to improve care transitions for these high-need Medicaid enrollees upon release and increase continuity of health coverage, prevent disruptions in care, and lead to improved health outcomes. This Waiver Watch summarizes the California approval and examines similar pending requests from 14 additional states to provide pre-release services.

What is the background?

The 2018 SUPPORT Act directed CMS to issue guidance on how waivers can improve care transitions for incarcerated individuals who are otherwise eligible for Medicaid. The SUPPORT Act required the Secretary of Health and Human Services (HHS) to convene a group of stakeholders to help inform the design of a demonstration opportunity to improve care transitions for individuals leaving incarceration. Findings from that convening were summarized in a report from the Office of the Assistant Secretary for Planning and Evaluation (ASPE), and the report includes promising practices and key considerations for the demonstration opportunity such as giving states options to customize the demonstration population, invest in data infrastructure, implement strategic partnerships, and include pre-arrest diversion activities. CMS has indicated that the guidance for the new waiver opportunity is forthcoming and will closely align with the approved approach to pre-release services in California.

States have used Medicaid strategies to help maintain eligibility and coordinate care for individuals transitioning from incarceration. While California is the first state to receive a partial waiver of the inmate exclusion, states can adopt other strategies to coordinate care for incarcerated Medicaid enrollees, such as by suspending (rather than terminating) eligibility for enrollees who became incarcerated and by developing managed care requirements and fee-for-service initiatives related to pre-release care coordination. The Biden Administration has encouraged states to propose waivers that address health-related social needs, expand coverage, and reduce health disparities, including by investing in initiatives for justice-involved populations.

What is included in the California waiver?

California estimates that approximately 200,000 people each year will be eligible to receive pre-release services under the demonstration waiver. While the waiver is complex and includes many provisions, key aspects of the “Reentry Demonstration Initiative” include the following:

• Eligibility based on health needs: Services will be available to all Medicaid-eligible adults who are inmates in state prisons and county jails and meet health criteria, beginning 90 days prior to their expected date of release. The health criteria aim to identify inmates at high risk of adverse health outcomes pre- and post-release, including those with behavioral health needs or other chronic conditions. Also, all inmates of youth correctional facilities will be eligible for services 90 days pre-release, without meeting any clinical criteria.
• Reentry benefit package: The limited benefit package is intended to improve care transitions for individuals upon release and prevent hospitalization as well as adverse outcomes including suicide, overdose, and recidivism. Covered services include case management, physical and behavioral health clinical consultation services, laboratory and radiology services, medications and medication administration, medication-assisted treatment (MAT) for substance use disorder, and Community Health Worker (CHW) services. Upon release, enrollees will also receive covered outpatient prescribed medications and over-the-counter drugs (a minimum 30-day supply, as clinically appropriate) and durable medical equipment (DME).
• Implementation timing and funds: The waiver also includes authority to spend $410 million on pre-release application planning and information technology through California’s “Providing Access and Transforming Health” (PATH) initiative. California will use these funds to provide capacity grants and case management services beginning in April 2024, with the pre-release service package being phased in over two years. California also must provide pre-release education and outreach, along with Medicaid eligibility and enrollment support, to all incarcerated individuals while the demonstration functions.

CMS recognizes that effective implementation of California’s pre-release services program will require forging new partnerships with and providing significant technical assistance to correctional authorities, providers, and community-based organizations. To help ensure access to care upon release and for other Medicaid enrollees, California is also required to increase and (at least) sustain base Medicaid payment rates of at least 80% of Medicare rates for primary care, behavioral health, and obstetrics providers (this requirement is consistent with other states that recently received approvals to address health-related social needs).

What is pending in other states?

As of February 7, 14 additional states are also seeking partial waivers to the inmate exclusion policy to provide pre-release services to some eligible incarcerated individuals (Figure 1). The parameters of these proposals may change to reflect the California approval and upcoming CMS guidance. Currently, these pending requests vary in scope by pre-release period, eligibility and benefits:

• Pre-release period. Most states (9 out of 15) intend to provide coverage to eligible inmates 30 days prior to release. Of the remaining states, three (New Hampshire, New Jersey, and Vermont) seek to provide coverage between 45 and 90 days prior to release. Kentucky proposes to provide fee-for-service benefits for the duration of an inmate’s commitment and through an MCO beginning 30 days prior to release. The other two states (Oregon and Massachusetts) would cover some inmates throughout the duration of their commitment, while covering other groups for a more limited pre-release period.
• Eligibility. Four states (Oregon, Rhode Island, Vermont, and Washington) are seeking to provide benefits to all inmates of state and county facilities. The remaining states would limit these services to inmates who meet health or risk criteria (frequently related to behavioral health needs).
• Benefits. Four states (Massachusetts, Rhode Island, Utah and Vermont) seek to provide full Medicaid State Plan benefits to eligible inmates during the pre-release period. Oregon proposes to provide full benefits to individuals in jail, while state prison inmates would receive a limited package of care coordination services. The remaining states would provide a limited benefit package for all eligible inmates (typically to include services such as reentry support, enhanced case management, and behavioral health care).

For further state-by-state details on Section 1115 pre-release requests, see Table 1.

Booster update remains modest; half of those already boosted are waiting for updated CDC guidelines to get another dose

Nearly four in ten (38%) people say their households were affected by this winter’s triple threat of viruses, with someone getting sick with the flu, COVID-19, or respiratory syncytial virus (RSV), and nearly half (46%) say the news of these three viruses spreading has made them more likely to wear masks or take other precautions to avoid getting sick, the latest KFF COVID-19 Vaccine Monitor survey finds.

At the same time, almost three years into the COVID-19 pandemic, most of the public says they are “not too” or “not at all” worried about getting seriously ill from the virus (69%), though 31% still say they are worried. That’s somewhat more than say the same about the flu (26%) or RSV (25%).

The flu affected the largest share of households over the past month or so (27%), with smaller shares saying someone in their homes got sick with COVID-19 (15%) or RSV (10%).

A relatively small share (14%) of adults in households affected by COVID-19 say they tried to get Paxlovid, the anti-viral prescription pill used to treat COVID-19. Similarly, among those households affected by the flu, 16% say they tried to get Tamiflu, an antiviral prescription medicine used to treat the flu.

Amid media reports of shortages of over-the-counter medicines often used to treat symptoms of these ailments, the survey finds that 75% of adults in affected households tried to obtain over-the-counter medicines such as Tylenol or cough syrup, including about one in five (representing 6% of all adults) who say they had difficulties getting that medicine.

News about the three viruses also made some people more likely to take preventive measures such as wearing a mask in public (31%), avoiding large gatherings (26%), traveling less (20%), or avoiding eating indoors at restaurants (18%).

People who say they are immunocompromised are more likely than those who aren’t to take many of those extra precautions. In addition, Black and Hispanic adults are more likely than White adults, and Democrats are more likely than Republicans, to say they are more likely to modify their behavior.

Nearly 3 in 10 Adults Now Say They’ve Gotten Updated Bivalent Booster Shot

As the federal government prepares to end its public health emergency declaration, the latest survey finds nearly three in ten (28%) adults report having received an updated COVID-19 bivalent vaccine booster shot, up slightly from December (22%). The increase largely reflects a shift in booster rates among Republicans (from 12% in December to 20% in January, though Democrats still are twice as likely to have gotten the updated booster (39%).

Among high-risk groups, nearly half (47%) of adults at least 65 years old, and about a third (36%) of those who are immunocompromised, say they have already received a bivalent booster dose.

Those who already received a bivalent booster are eager to get an additional booster in the future. The vast majority (86%) say that getting another shot is important to them, and just over half (54%) say they are waiting for the Centers for Disease Control and Prevention (CDC) to issue new guidelines to make them eligible for another booster.

On the other side, vaccinated adults who have not gotten the bivalent booster yet cite a number of reasons for why they haven’t done so.  Half (51%) say they feel they have enough protection from their initial vaccination or a prior infection, and nearly as many (44%) say they don’t think they need the new booster.

Smaller shares say that they have been too busy or have not had the time to get the updated booster (29%), that they had bad side effects from a previous dose (19%), or that they cannot afford to take time off work to get the shot and deal with side effects from the vaccine (15%).

Designed and analyzed by public opinion researchers at KFF, the survey was conducted from January 17-24, 2023, online and by telephone among a nationally representative sample of 1,234 U.S. adults, in English and in Spanish. The margin of sampling error is plus or minus 4 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

The KFF COVID-19 Vaccine Monitor is an ongoing research project tracking the public’s attitudes and experiences with COVID-19 vaccinations. Using a combination of surveys and qualitative research, this project tracks the dynamic nature of public opinion as vaccine development and distribution unfold, including vaccine confidence and acceptance, information needs, trusted messengers and messages, as well as the public’s experiences with vaccination.

On Jan. 30, 2023, the Biden Administration announced it will end the public health emergency (and national emergency) declarations on May 11, 2023. Here’s what major health policies will and won’t change when the public health emergency ends.

Vaccines

What’s changing: Nothing. The availability, access, and costs of COVID-19 vaccines, including boosters, are determined by the supply of federally purchased vaccines, not the public health emergency.

What’s the same: As long as federally purchased vaccines last, COVID-19 vaccines will remain free to all people, regardless of insurance coverage. Providers of federally purchased vaccines are not allowed to charge patients or deny vaccines based on the recipient’s coverage or network status.

Although a federal rule temporarily required private insurers to reimburse out-of-network providers for vaccine administration during the public health emergency, vaccine access will be unaffected by insurers ending these payments, as long as federal supplies last, because vaccine providers are not allowed to deny anyone a federally purchased vaccine based the recipient’s coverage or network status and must not charge any out-of-pocket costs.

Due to the Affordable Care Act and other recent legislation, even after the federal supply of vaccines is gone, vaccines will continue to be free of charge to the vast majority of people with private and public insurance. However, costs may become a barrier for uninsured and underinsured adults when federally purchased doses are depleted, and privately insured people may then need to confirm their provider is in-network. For more on what happens after the federal supply of vaccines runs dry, see our briefs on the commercialization of COVID vaccines and the expected growth in prices for COVID vaccines.

Importantly, the Food and Drug Administration (FDA)’s emergency use authorizations for COVID-19 vaccines (and treatments and tests) will remain in effect, as they are tied to a separate emergency declaration, not the public health emergency that ends in May.

At-home COVID tests

What’s changing: At-home (or over-the-counter) tests may become more costly for people with insurance. After May 11, 2023, people with traditional Medicare will no longer receive free, at-home tests. Those with private insurance and Medicare Advantage (private Medicare plans) no longer will be guaranteed free at-home tests, but some insurers may continue to voluntarily cover them.

For those on Medicaid, at-home tests will be covered at no-cost through September 2024. After that date, home test coverage will vary by state.

A temporary Medicaid coverage option adopted by 15 states has given uninsured people access to COVID-19 testing services, including at-home tests, without cost-sharing but that program will end with the public health emergency.

What’s the same: Uninsured people in most states were already paying full price for at-home tests as they weren’t eligible for the temporary Medicaid coverage for COVID testing services. Uninsured and other people who cannot afford at-home tests may still be able to find them at a free clinic, community health center, public health department, library, or other local organization. Additionally, some tests have been provided by mail through the federal government, though supply is diminishing.

PCR and rapid tests ordered or administered by a health professional

What’s changing: Although most insured people will still have coverage of COVID tests ordered or administered by a health professional, these tests may no longer be free.

• For people with traditional Medicare, there will be no cost for the test itself, but there could be cost-sharing for the associated doctor’s visit.
• For people with Medicare Advantage and private insurance, the test and the associated doctor’s visit both might be subject to cost-sharing, depending on the plan. Additionally, some insurers might begin to limit the number of covered tests or require tests be done by in-network providers. People in grandfathered or non-ACA-compliant plans will have no guarantee of coverage for tests and may have to pay full-price.

• For people with Medicaid, there will continue to be free tests through September 2024, after which point, states may limit the number of covered tests or impose nominal cost-sharing.
• Uninsured people in the 15 states that have adopted the temporary Medicaid coverage option will no longer be able to obtain COVID-19 testing services, including at-home tests, with no cost-sharing as this program ends with the public health emergency.

What’s the same: Uninsured people in most states were not eligible for the temporary Medicaid pathway for COVID testing and therefore will continue to pay full price for tests unless they can get tested through a free clinic or community health center.

COVID Treatment

What’s changing: People with public coverage may start to face new cost-sharing for pharmaceutical COVID treatments (unless those doses were purchased by the federal government, as discussed below). Medicare beneficiaries may face cost-sharing requirements for certain COVID pharmaceutical treatments after May 11. Medicaid and CHIP programs will continue to cover all pharmaceutical treatments with no-cost sharing through September 2024. After that date, these treatments will continue to be covered; however, states may impose utilization limits and nominal cost-sharing.

What’s the same: Any pharmaceutical treatment doses (e.g. Paxlovid) purchased by the federal government are still free to all, regardless of insurance coverage. This is based on the availability of the federal supply and is not affected by the end of the public health emergency.

Most insured people already faced cost-sharing for hospitalizations and outpatient visits related to COVID treatment. Private insurers were never required to waive cost-sharing for any COVID treatment. Though some did so voluntarily, most insurers had already phased out these waivers more than a year ago.

Telemedicine

What’s changing: Some flexibilities associated with providing health care via telehealth during the public health emergency will end.

• During the public health emergency, providers writing prescriptions for controlled substances were allowed to do so via telemedicine, but in-person visits will be required after May 11.
• Because of the pandemic, all states and D.C. temporarily waived some aspects of state licensure requirements so that providers with equivalent licenses in other states could practice remotely via telehealth. Some states tied those policies to the end of the federal public health emergency so those policies may end unless those states change their policy.
• The Department of Health and Human Services temporarily waived penalties against providers using technologies that don’t comply with federal privacy and security rues in the provision of telehealth services during the public health emergency. Enforcement of these rules when the public health emergency ends will restrict the provision of telehealth to so-called “HIPAA compliant” technologies and communication productions.

What’s the same: Expanded telehealth for Medicare beneficiaries was once tied to the public health emergency but, due to recent legislation, will remain unchanged through December 31, 2024. Most private insurers already covered telemedicine before the pandemic. In Medicaid, states have broad authority to cover telehealth without federal approval. Most states have made, or plan to make, some Medicaid telehealth flexibilities permanent.

Discussion

Overall, the widest ranging impact from the end of the public health emergency will likely be higher costs for COVID tests – both at-home tests and those performed by clinicians. As many Americans delay or go without needed care due to cost, the end of free COVID tests could have broad implications for the people’s ability to get timely COVID diagnoses or prevent transmission. Other changes to health policies that are tied to the public health emergency, national emergency, and other declarations are discussed in more detail in our earlier brief.

Further, and potentially more significant, changes will come when federal supplies of vaccines, treatments, and tests are depleted, though the timing of that is yet to be determined and is not tied to the public health emergency. The Biden administration has announced that it has no further funding for vaccines, tests, or treatments, and that Congress would need to make more funding available.

Importantly, continuous enrollment for Medicaid enrollees – which has led to record-high enrollment in Medicaid – was once tied to the end of the public health emergency. However, recent legislation decoupled this provision from the public health emergency and ends continuous enrollment on March 31, 2023. States can begin disenrolling people from Medicaid as early as April 1, 2023, though most states will take a year to complete these disenrollments. KFF has estimated that millions of people will lose Medicaid coverage during this unwinding period.