A current impasse in Congress threatens continued funding for COVID-19 testing, treatment, and vaccines. The White House asked Congress for an additional $22.5 billion to support domestic and global COVID-19 efforts. During the recent negotiations to fund the federal government for FY 2022, Congress reduced this amount to $15.6 billion and it was subsequently stripped from the final bill. Without additional resources, the White House has said that several programs will need to be discontinued, including the Health Resources and Services Administration (HRSA) COVID-19 Uninsured Program, established to reimburse health care providers for the costs of delivering COVID-19 testing and treatment services and administering vaccines to those who are uninsured. HRSA has announced that due to lack of funding, the program stopped accepting reimbursement claims for COVID-19 testing and treatment services on March 22, 2022 and will stop accepting claims for vaccine administration on April 5, 2022. In addition, the federal government has said it does not have funding to purchase additional COVID-19 tests, treatments, and vaccines once current supplies run out, and that it does not currently have a sufficient supply for vaccines to cover fourth doses if they are eventually recommended (also the subject of a recent KFF analysis). The lack of additional COVID-19 funding has broad implications for access to these services, particularly for people who are uninsured, and could undermine efforts to ensure equitable access to these resources.

How have COVID-19 testing, treatment, and vaccines been paid for so far?

The federal government has purchased COVID-19 tests, treatments, and vaccines and made them available to individuals at no cost, regardless of their insurance status. During the pandemic, the federal government has used emergency COVID-19 funding provided through multiple appropriations to purchase supplies of vaccines, rapid and some PCR tests, and some treatments (such as monoclonal antibodies and antivirals) and has distributed these resources through pharmacies, community health centers, federal sites, and allocations to states and localities. The availability of these government-purchased supplies has been instrumental in supporting large-scale testing and vaccination efforts and, to a lesser extent, treatment. A distribution program with health centers has also promoted more equitable distribution of tests, antiviral pills and vaccines and helped improve access in medically underserved communities.

Federal funding has also supported the HRSA COVID-19 Uninsured Program, which reimburses providers for the costs of providing COVID-19 testing and treatment services and vaccine administration to people who are uninsured. While providers are not required to participate in the program, those that do agree to accept reimbursement from the program, generally paid at Medicare rates, and are prohibited from balance billing the patient for any costs not covered by the payment. Although the program did not eliminate all barriers uninsured individuals face in accessing care, it did offer an avenue to obtain testing and vaccines as well as some treatment services without cost-sharing. Since the beginning of the pandemic, the program has provided about $19 billion in reimbursement for COVID-19 related uninsured claims, with 60% of reimbursements for COVID-19 testing claims, 31% for treatment claims, and 9% for vaccine administration.

Beyond the HRSA program, in 15 states, Medicaid coverage is available to cover the cost of providing COVID-19 testing, treatment services, and vaccines to uninsured individuals. Provisions in the Families First Coronavirus Response Act (FFCRA) gave states the option to provide Medicaid coverage for COVID-19 testing to people who are uninsured, regardless of their income, and receive 100% federal matching funds to cover the costs of providing care.¹  This coverage was later expanded to include provision of COVID-19 treatment services and vaccines. As of July 1, 2021, 15 states had adopted this option. While this coverage is not dependent on further federal funding, it is only available through the end of the month in which the COVID-19 public health emergency (PHE) ends.

For people with health coverage, COVID-19 diagnostic testing, treatment, and vaccines are generally covered services and providers can seek reimbursement for COVID-19 related costs from insurance companies and public programs. Federal law requires all private insurance plans, Medicaid, and Medicare to cover diagnostic COVID-19 testing during the PHE, although the Medicaid and Medicare programs may require a physician’s order. While testing services are provided at no cost to individuals, providers can seek reimbursement from insurers, Medicaid, and Medicare for the costs of administering the tests and any related costs. Similarly, providers are required to provide COVID-19 vaccines without cost-sharing regardless of insurance status, but they can bill insurance plans and public programs for the costs of administering the vaccine (with the vaccines themselves paid for by the federal government). Currently, COVID-19 treatment medications, including monoclonal antibodies and antiviral pills, are limited and most available medications have been purchased by the federal government and allocated to states for distribution to providers and pharmacies. Individuals cannot be charged for the cost of government-purchased treatments, and reimbursement for the costs of administering or dispensing the medications is available through insurers and Medicaid and Medicare. People may face cost-sharing for other treatment services, such as physician visits and/or hospital care. Some insurers waived cost-sharing for COVID-19 treatment early in the pandemic, but most have since phased out these waivers.

Who will pay for testing, treatment, and vaccines when federal COVID-19 funding runs out?

The current supply of tests, treatments, and vaccines that have already been purchased by the federal government will remain free to people regardless of insurance status. The federal government will continue allocating these resources to states and localities and to federal partners, including pharmacies and health centers, though allocations of treatment medications may be reduced to stretch existing supplies.

Even while existing supplies remain, some providers will lose access to reimbursement for vaccine administration and other costs associated with providing testing and treatment for uninsured people without additional funding from Congress. As noted above, the HRSA COVID-19 Uninsured Program is no longer accepting reimbursement claims for COVID-19 testing and treatment services and will stop accepting claims for vaccine administration on April 5, 2022. In states that have not adopted the temporary Medicaid coverage option, providers will no longer have a source of reimbursement for administration costs or other services provided to uninsured individuals. Although all providers must continue to provide vaccines at no cost, some providers may start billing patients for other COVID-related services, while others may stop providing the services altogether. In other cases, the loss of funding may increase the financial strain on safety net providers that continue to provide the services regardless of patients’ ability to pay. Whichever way providers respond, the result will likely be reduced access for uninsured patients in most states due to more limited provider access and/or potential out-of-pocket costs.

Some uninsured children and adults may be able to access the COVID-19 vaccine through existing immunization programs. There are currently two federal programs that provide vaccines to uninsured children and adults—the Vaccines for Children Program (VCF) and the Section 317 Vaccine program. The VCF program is an entitlement program guaranteeing eligible children access to vaccines recommended by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP). The CDC will determine if the COVID-19 vaccine will be included in the VFC program. Providers participating in the VFC program may charge a vaccine administration fee but cannot deny access to the vaccine if the patient or parent is unable to pay. The Section 317 Vaccine program, which provides approved vaccines for uninsured adults, is dependent on available funding. The CDC will similarly determine if the COVID-19 vaccine will be included in the Section 317 program. If it is, uninsured adults will be able to access the COVID-19 vaccine through the Section 317 program; however, without additional funding, it is likely that only a limited supply of COVID-19 vaccines would be available through this program.

Existing rules and protections will ensure that most people with health coverage will continue to have free access to COVID-19 tests, some treatment services, and vaccines, though some limits on cost sharing will end when the PHE ends.

• Medicaid is required to cover COVID-19 testing and treatment services for full-benefit enrollees with no cost sharing for at least a year after the PHE ends, although states may require a prescription for or place other limits on COVID-19 tests. Medicaid must also cover COVID-19 vaccines and administration for nearly all enrollees, and states receive 100% federal matching payments for the costs of administering the COVID-19 vaccine for more than a year after the PHE ends.
• For privately insured individuals, rules in place during the PHE require insurers to cover COVID-19 testing without cost sharing and prohibit insurers from requiring prior authorization for COVID-19 testing. However, when the PHE ends, these requirements will also end, and insurers could begin charging cost sharing for COVID-19 tests or otherwise limiting access. Most privately insured individuals can also access the COVID-19 vaccine at no cost because the vaccine is recommended by ACIP and the Affordable Care Act requires insurers to cover ACIP-recommended vaccines without cost-sharing. This requirement is not tied to the PHE, although once the PHE ends, insured consumers who receive vaccines from out-of-network providers could face higher costs. COVID-19 treatment medications, including monoclonal antibodies and antiviral pills, are generally covered for people with private insurance but once government-purchased supplies run out, will be subject to existing cost sharing requirements, including copayments, coinsurance, and deductibles, as is currently the case for most other treatment-related services, such as physician or hospital care. Though for a time private insurers and employers were waiving out-of-pocket cost sharing for COVID-19 physician or hospital care, the vast majority of the largest insurers and employers have phased out those waivers. Meaning, privately insured COVID-19 patients are expected to pay deductibles and other cost-sharing under their plan.
• Medicare will continue to provide diagnostic COVID-19 testing and testing-related services with no cost sharing during the PHE, though a health care provider’s order may be required. When the PHE ends, while the test will be provided at no cost, beneficiaries will face cost sharing for testing-related office visits and other testing-related services. Medicare will also cover the COVID-19 vaccine under Part B with no cost sharing for the vaccine or its administration for Medicare beneficiaries in both traditional Medicare and Medicare Advantage plans. Medicare covers monoclonal antibody infusions authorized for use by the U.S. Food and Drug Administration (FDA) under an emergency use authorization (EUA), prior to full FDA approval that are provided in outpatient settings, and beneficiaries currently face no cost sharing for this treatment (though that may change when the PHE ends). Antiviral treatments for COVID-19 will likely be covered under Medicare Part D once they are approved by the FDA; however, the definition of a Part D covered drug does not include drugs authorized for use by the FDA but not FDA-approved. CMS recently issued guidance to Part D plan sponsors, including both stand-alone drug plans and Medicare Advantage prescription drug plans, that provides them flexibilities to offer these oral antivirals to their enrollees and strongly encourages them to do so, though this is not a requirement. It is not yet known what beneficiaries may be required to pay for these drugs when covered under Part D, nor how beneficiaries who are not enrolled in Part D plans would get coverage of these medications.

What will happen when the current supply of federally purchased tests, treatments, and vaccines runs out?

Once the current supply runs out, the federal government cannot purchase more tests, treatments, or vaccines without additional Congressional appropriations. Without federally purchased supplies, uninsured individuals would likely need to pay out of pocket for testing and treatment services and/or safety-net providers would have to absorb the cost of providing these services without a reimbursement mechanism. As noted, there are some federal programs that may help cover the costs of providing vaccines to uninsured people, but, without additional funding, it is unlikely that these programs will be able to fully absorb the costs of providing COVID-19 vaccines for adults. People covered by Medicaid and Medicare will continue to have access to COVID-19 clinical diagnostic tests and vaccines without cost sharing and while COVID-19 treatment medications will be covered at no cost for people on Medicaid, Medicare beneficiaries may face out-of-pocket costs for these medications when the PHE ends. For privately insured people, if the costs of treatment medications and vaccines are shifted to private insurers, the insurers will need to establish new contracts and negotiate prices to purchase these supplies, which will take time and may lead to higher costs that could translate into higher premiums for employers and individuals. Insurers may also have a difficult time competing with other countries in purchasing vaccines.

The federal government’s inability to purchase additional supplies of COVID-19 tests, treatment medications, and vaccines could exacerbate existing disparities in health and financial security. People of color are more likely to be uninsured than their White counterparts and face more potential barriers to accessing care, including more limited transportation options and less flexibility in work and caregiving schedules. Even when COVID-19 vaccines have been available for free, survey data show that concerns about costs have been a bigger barrier to vaccination for people of color. While overall disparities in COVID-19 cases and deaths have narrowed over time, data continue to show that people of color are disproportionately impacted by surges caused by new variants, and, as such, may have increased needs for testing and treatment. Moreover, data show a continued gap in vaccinations among Black people and point to racial disparities in uptake of booster shots so far. Any changes that result in more limited access to COVID-19 testing, treatment services, or vaccines, or that require people to pay out-of-pocket for these services, will likely exacerbate these disparities and may also result in more financial burden. Such changes would also disproportionately affect low-income people and those who are uninsured.

Beyond the challenges individuals may face accessing COVID-19 testing, treatments, and vaccines, there are broader implications for the ongoing availability of these resources if the federal government is no longer able to purchase these supplies. Federal pre-purchasing of these supplies to date has provided a guaranteed market to manufacturers (locking in their availability for domestic use) and ensured that the U.S. has had initial access to the supplies. Without such pre-purchasing, manufacturers may reduce or halt production when demand declines (as has happened already with rapid tests) and/or it may become more difficult for the U.S. or for insurance companies to access supplies, as they will be in line with other purchasers globally. Together, this could contribute to shortages of supplies if and when the next COVID-19 wave hits and demand increases.

1. In states that have taken up this option, providers cannot claim reimbursement from the HRSA COVID-19 Uninsured Program for individuals that qualify for the Medicaid uninsured program. ↩︎

With funding for additional COVID-19 support at a stalemate in Congress, a new KFF analysis looks at potential scenarios that United States might face if a 4th COVID-19 vaccine dose is recommended to the public. The analysis finds that the U.S. government does not have enough funding to purchase vaccine doses remaining to fully cover the population under any of the predicted scenarios.

If 4th doses are authorized and recommended for all ages, there will be a deficit of almost half a billion doses to cover everyone, including fully vaccinating those not yet up to date with their vaccinations. If 4th doses are provided only to people ages 65 and older, the deficit would be 162.5 million doses with the current supply.

Under a scenario where enough doses are purchased to vaccinate 70% of the population, the U.S. would still experience a vaccine supply deficit of 118.3 million doses to provide 4th doses to people of all ages.

Currently, there are only enough doses in the existing supply to provide 70% of those ages 65 and older with a 4th dose. To date, 65% of the U.S. population has been fully vaccinated.

The additional funding necessary to accommodate a 4th dose ranges from about half a billion dollars to over $9 billion, depending on the recommendations for different age groups and whether the doses are for the lower-priced Moderna vaccine or the higher-priced Pfizer shot.

Update: On March 29, 2022, the Food and Drug Administration (FDA) authorized a second booster dose (4th dose) for those ages 50 and older (and for immunocompromised individuals). We have added the 50+ scenario to our analysis.

With Congress having reached a funding stalemate regarding additional COVID-19 support, the White House has said that the federal government “does not have adequate resources to purchase enough booster vaccine doses for all Americans, if additional doses are needed.”  We sought to assess this by estimating how far the current U.S. supply of COVID-19 vaccines could stretch under different scenarios. To do so, we looked at the number of COVID-19 vaccine doses the federal government has already purchased, the number of people already vaccinated and boosted. We then estimated the number of additional doses that would be required to fill any gaps needed to reach vaccination targets, including to fully vaccinate those who still haven’t completed a primary series, under different assumptions about further booster coverage with 3^rd and 4^th doses. We assumed that primary vaccination will soon be authorized for all ages, and examined the future supply of mRNA vaccine doses only (i.e., Johnson and Johnson doses were not included). We assessed the following four scenarios:

1. Providing a 4^th dose to those ages 50 and older
2. Providing a 4^th dose to those ages 65 and older
3. Providing a 4^th dose to those ages 18 and older
4. Providing a 4^th dose to all ages

For each scenario, we looked at supply needed to purchase enough doses to reach two vaccine coverage targets: 70% and 100%. Data are as of March 20, 2022 (see methods for sources and additional details).

Findings

• We find that the federal government does not have enough vaccine doses remaining in its current supply to fully cover the U.S. population with a 4^th dose under any of these scenarios.
• The deficit between current supply and doses required is most acute (484 million doses) if a 4^th dose is authorized for all ages and enough doses are purchased to cover 100% of the population. However, a deficit still exists even if 4^th doses are needed only for those ages 65 and older (162.5 million doses), as well as for the larger age group of people 50 and older (a deficit of 225 million doses), as authorized by the FDA on March 29..
• When a 70% population coverage target is used instead, there is still a supply deficit (118.3 million doses) if 4^th doses are purchased for those of all ages, and a modest deficit to reach 70% of those ages 18 and older with a 4^th dose (34 million). There are enough doses to cover 70% of those ages 65 and older with a 4^th dose as well as 70% of those ages 50 and older.
• Based on the lowest available prices paid per dose by the U.S. government for domestic vaccine supply ($15.00/dose for Moderna and $19.50 for Pfizer), we estimate that additional funding required ranges from $509.5 million (if all future doses were Moderna and enough were purchased to reach 70% coverage of those 18 and older with a 4^th dose) to $9.4 billion (if all future doses were Pfizer and enough were purchased to reach 100% of all ages with a 4^th dose).

With the FDA authorizing a 4^th dose for those ages 50 and older, our analysis finds that the U.S. government currently has purchased enough vaccine doses for 70% of this age group to receive a 4^th dose, and for completing vaccination for others. While the government does not have enough doses to cover all those ages 50 and older, it is also unlikely that 4th dose take-up will approach 100% of the population anytime soon. If 4th dose authorization is further expanded, potential supply constraints will grow.

Over two years into the COVID-19 pandemic, many people continue to grapple with worsened mental health associated with social distancing, income loss, and death and illness. Roughly one-third (32%) of adults in the United States reported symptoms of anxiety and/or depressive disorder in February 2022. Among these adults, 27% reported having unmet mental health care needs.

In this data note, we explore how the use of mental health care varied across populations reporting poor mental health before the pandemic using data from the National Health Interview Survey (NHIS) in 2019. The 2019 NHIS data included detailed questions on symptoms of anxiety and depression. These questions were not asked on the 2020 survey, so pandemic-era NHIS data will not be available until the 2021 survey is released later this year.

In this analysis, we find that leading up to the pandemic, 8.5 million adults reported moderate to severe symptoms of anxiety and/or depression but did not receive treatment either through therapy or prescription drugs in the past year. Among adults reporting moderate to severe symptoms of anxiety and/or depression, receipt of mental health treatment was lowest among several demographic groups – including young adults, Black adults, men, and uninsured people. These data provide a useful baseline for understanding disparities in mental health treatment that were already present before the pandemic, and may have been exacerbated by the public health crisis.

How many adults report symptoms of anxiety/depression and receipt of treatment overall?

Prior to the pandemic, nearly 1 in 4 adults (23% of people ages 18 and above) reported symptoms of anxiety and/or depression (Figure 1). Fourteen percent of adults reported mild symptoms of anxiety and/or depression while 5% reported moderate symptoms and 4% reported severe symptoms (Figure 1).  In total, 54.9 million adults reported at least mild symptoms, with 9.5 million having severe symptoms. Anxiety and depression can affect quality of life and often co-occur with physical health problems.

Many adults with mental health conditions do not receive care. In 2019, 21.6 million adults reported moderate to severe symptoms of anxiety and/or depression. Among these adults, 8.5 million (39%) were not receiving treatment (Figure 2). Treatment is defined as receiving counseling and/or taking prescription medication for mental health, depression and/or anxiety in the past year. Among the 9.5 million adults reporting severe symptoms of anxiety and/or depressive disorder, 3.1 million (32%) were not receiving treatment.

A number of factors may contribute to not receiving mental health care. Among those reporting symptoms of moderate or severe anxiety and/or depressive disorder, who were not receiving treatment, 23% indicated that they skipped or delayed therapy due to cost. Other data from 2019 found that among adults with any mental illness in the past year and unmet needs for mental health care, 25% cited not knowing where to obtain care as a reason they did not access services. Widespread mental health provider shortages coupled with low rates of insurance acceptance may also contribute to treatment barriers.

How does reporting of symptoms of anxiety/depression and receipt of treatment vary by demographic characteristics and insurance coverage?

The share of adults reporting moderate to severe symptoms of anxiety and/or depression varied across some demographic groups and by insurance coverage. In 2019, more women (11%) than men (7%) reported moderate to severe symptoms of anxiety and/or depression (Figure 3). A disproportionate share of adults that reported moderate to severe symptoms of anxiety and/or depression were enrolled in Medicaid (19%) and a smaller share are enrolled in an employer plan (6%).

How does receipt of mental health treatment vary by demographic characteristics and insurance coverage?

Leading up to the pandemic, disparities in receipt of mental health care existed across age, racial and ethnic groups, gender, and insurance status. In 2019, 10% of young adults (ages 18-26) reported moderate to severe symptoms of anxiety and/or depressive disorders, similar to older adults. More than half (55%) of these young adults reporting moderate or severe symptoms reported not receiving mental health treatment in the past year; this is significantly higher than the share of older adults reporting similar symptoms who were not receiving treatment (38% for ages 27-50; 32% for ages 51-64; and 38% for ages 65 and up) (Figure 4). Some research suggests that costs and factors associated with transitioning from pediatric to adult health care may be linked to limited mental health treatment among young adults in need of care.

In 2019, nine percent of White, nine percent of Black, and eight percent of Hispanic adults reported moderate or severe symptoms of anxiety and/or depressive disorder. Despite substantively similar reporting of mental health symptoms across racial and ethnic groups, receipt of treatment varied considerably - compared to White adults (36%), a much larger share of Black adults (53%) with moderate to severe symptoms of anxiety and/or depressive disorder did not receive treatment in the past year (Figure 5). In contrast, there was no significant difference in receipt of treatment between Hispanic and White adults. Data were not sufficient to conduct analyses for other racial groups. Research suggests that structural inequities may contribute to disparities in use of mental health care, including lack of health insurance coverage and financial and logistical barriers to accessing care. Moreover, lack of a diverse mental health care workforce, the absence of culturally informed treatment options, and stereotypes and discrimination associated with poor mental health may also contribute to limited mental health treatment among Black adults.

Men (7%) were less likely than women (11%) to report moderate to severe symptoms of anxiety and/or depressive disorder prior to the pandemic (Figure 3). At the same time, men (47%) with moderate to severe symptoms of anxiety and/or depressive disorder were more likely than women (35%) to not receive mental health treatment in the past year (Figure 6). Some research suggests men may be less likely to seek mental health care. Men are also more likely to be uninsured and less likely to report a usual source of care.

Uninsured adults with moderate to severe symptoms of anxiety and/or depression (62%) were significantly more likely to not receive mental health care compared to their insured counterparts (36%) in 2019. Narrow mental health networks in private insurance plans, including nongroup plans may be linked to access issues. Prior to the pandemic, individuals enrolled in nongroup plans commonly reported delayed or forgone care due to cost. Many employers have indicated that they have narrower provider networks for mental health services than other health care.

Despite having insurance coverage, insured adults with moderate or severe symptoms of anxiety and/or depression and a usual source of outpatient care (57%) were more likely to not receive mental health treatment than those with a usual source of care (34%) in 2019 (Figure 8). Individuals with a usual source of care may receive mental health treatment directly or through referrals to specialized mental health treatment within or outside their usual care source. Having a usual source of care may improve but does not ensure mental health treatment. Irregular or no mental health screening in outpatient settings, difficulty finding or paying for mental health services, and coverage limitations may contribute to the lack of treatment, even among insured individuals who report a usual source of care.

How have mental health concerns and access to care changed since the pandemic?

An increasing share of people across the U.S. have reported poor mental health since the pandemic began. Some populations – including young adults and some communities of color – have fared worse during the pandemic. Higher shares of young adults reported symptoms of anxiety and/or depressive disorder, increased substance use, and thoughts of suicide compared to older adults. Mental distress and deaths due to drug overdose have also disproportionately increased among some adults of color compared to White adults. Additionally, Black and Hispanic adults have been more likely to experience negative financial impacts and higher rates of COVID-illness and death compared to White adults.

Barriers to accessing mental health care predate the pandemic, though they may have worsened in recent years, particularly for at-risk groups. Some steps have been taken to address challenges in accessing mental health care during the pandemic. Telehealth has played an important role in delivering mental health care during the pandemic. Restrictions around the use of telehealth and prescribing over telehealth were temporarily eased as were some state laws around provider licensing and practice authority. In 2021, the American Rescue Plan Act allocated some funds toward behavioral health workforce development and developing mental health mobile crisis support teams. Additionally, the national suicide hotline number, ‘988’, is set to launch in July 2022. There have also been some bipartisan efforts in response to the mental health crisis, including proposed mental health packages and a legislative agenda from the Addiction and Mental Health Task force. Recently, the Biden administration announced its Unity Agenda which proposes improving behavioral health workforce capacity, improving access to care in integrated settings, and expanding insurer coverage requirements. It is unclear how recent policy measures will impact access to mental health treatment especially among groups who experienced barriers to care even before the pandemic.

Several legislative proposals in Congress propose a $35 per month cap on what people with health insurance would have to pay out of pocket for insulin, a life-saving hormone taken regularly by many people with diabetes to maintain their health.

This analysis of insurance claims data finds that such a cap could provide financial relief to at least 1 out of 5 insulin users with different types of private health insurance.

Among people with private insurance who currently pay more than $35 per month for insulin on average, half would save at least $19 per month, and a quarter would save at least $42 per month. Savings are highest among people who buy their own insurance.

The report analyzes 2018 claims data from the Centers for Medicare and Medicaid Services EDGE data for the individual and small-group markets and the IBM Health Analytics MarketScan Commercial Claims and Encounters Database for the large-employer market. It is available through the KFF-Peterson Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Several legislative proposals in Congress propose a $35 per month cap on what people with health insurance would have to pay out of pocket for insulin, a life-saving hormone taken regularly by many people with diabetes to maintain their health.

Such a cap could provide financial relief to at least 1 out of 5 insulin users with different types of private health insurance, a new KFF analysis of insurance claims data finds.

In the large employer market, 19% of people who take insulin spend an average of more than $35 per month ($420 annually) for insulin, the analysis shows. The shares are even higher for insulin users covered through the small group market (31%) and individual market (26%).

People in small group plans may face higher out-of-pocket costs for insulin because such coverage is generally less comprehensive than in large employer plans, and there is no reduced cost-sharing for low-income people as there is for individual market plans purchased through the Affordable Care Act’s marketplaces.

Among people with private insurance who currently pay more than $35 per month for insulin on average, half would save at least $19 per month, and a quarter would save at least $42 per month. Savings are highest among people who buy their own insurance.

The $35 per month cap on insulin out-of-pocket costs is the main provision in the Affordable Insulin Now Act, introduced in February 2022 by Sen. Raphael Warnock, and one of many drug-pricing provisions in the Build Back Better Act, which passed the House last year but stalled in the Senate.

The report analyzes 2018 claims data from the Centers for Medicare and Medicaid Services EDGE data for the individual and small-group markets and the IBM Health Analytics MarketScan Commercial Claims and Encounters Database for the large-employer market. It is available through the KFF-Peterson Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Why will MCOs be important with PHE unwinding?

Medicaid managed care organizations (MCOs) deliver care to more than two-thirds of all Medicaid beneficiaries nationally. Medicaid MCOs (also referred to as managed care plans) may be in contact with enrollees as they provide care coordination and other member services (e.g., health education and promotion, call center support) and may conduct periodic outreach to promote appropriate use of care (e.g., to encourage prevention, wellness, and early intervention). Throughout the pandemic, states have worked with managed care plans to respond to changing public health conditions and new developments, including to promote the take-up of COVID-19 vaccinations.

Medicaid MCOs have seen growth in their membership during the pandemic that tracks overall Medicaid enrollment trends. Enrollment growth reflects downturns in the economy due to the pandemic and provisions in the Families First Coronavirus Response Act (FFCRA) that require states to ensure continuous enrollment for current Medicaid enrollees to access a temporary increase in the Medicaid match rate during the Public Health Emergency (PHE) period. It is expected that the PHE will be extended through at least mid-July 2022 since the Biden administration indicated it would give states 60 days-notice before the PHE is terminated or is allowed to expire (the current PHE is set to expire in mid-April). If the PHE ends in mid-July, the continuous enrollment requirement would expire at the beginning of August 2022.

Medicaid managed care plans can assist state Medicaid agencies in communicating with enrollees, conducting outreach and assistance, and ultimately, in improving coverage retention (including facilitating transitions to the Marketplace where appropriate). After the PHE ends, state Medicaid agencies will need to complete a large number of eligibility and enrollment tasks and actions, including processing renewals, redeterminations (based on changes in circumstance), and post-enrollment verifications. Current CMS guidance indicates states must initiate all renewals and other outstanding eligibility actions within 12 months after the PHE ends. Medicaid managed care plans have a financial interest in maintaining enrollment, which could also prevent disruptions in care for enrollees, including prescription drug benefits. Four for-profit parent firms that account for about 40% of Medicaid enrollment nationally (Anthem, Centene, Molina, and UnitedHealth Group) reported on Q4 2021 earnings calls that they expect modest enrollment declines in their Medicaid membership after the continuous enrollment requirement ends. However, these firms also indicated expecting to pick up/capture many individuals who transition from Medicaid through their other lines of business (i.e., the Affordable Care Act Marketplace and employer sponsored insurance (ESI)). Managed care plans have long cited lack of continuous eligibility, or churn, as a key challenge in ensuring access to care and for care continuity.

How can states engage MCOs to help individuals retain Medicaid coverage or transition to other coverage?

CMS released guidance for state Medicaid agencies on resuming normal operations including outlining strategies for working with managed care plans to promote continuity of coverage when the continuous enrollment requirement during the PHE ends. In the guidance, CMS notes that the federal Medicaid managed care marketing rules (42 CFR 438.104) do not prohibit plans from providing information and conducting general outreach on behalf of states. States must develop an “unwinding operational plan” to document their comprehensive plan to resume normal operations in their Medicaid and Children’s Health Insurance Program (CHIP) programs. CMS is encouraging states to gather input on their unwinding plans, including from managed care plans. Key strategies from the CMS guidance include:

• Working with plans to obtain and update beneficiary contact information. States may direct MCOs to seek updated contact information from enrollees. Plans must confirm the accuracy of updates received from a third party (e.g., provider) with enrollees directly. MCOs may share this information with the state or may instruct 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. While guidance expects plans to help in updating contact information, plans have historically cited difficulty reaching members and inaccurate member contact information as key barriers to engaging enrollees in care coordination activities. While state plans are evolving, as of January 2022, about half of states reported working with managed care plans to update beneficiary mailing addresses before the end of the PHE.
• Sharing renewal files with MCOs to conduct outreach and provide support to individuals enrolled in Medicaid during their renewal period. States can provide monthly files to MCOs containing information about beneficiaries for whom the state is initiating the renewal process, or beneficiaries who have yet to submit renewal forms or other documentation and are at risk of losing coverage, to enable plans to conduct outreach and provide assistance with the renewal process. Prior to sharing information with managed care plans (e.g., renewal files), states may need to identify and address possible systems or operational challenges, including to ensure data accuracy.
• Enabling MCOs to conduct outreach to individuals who have recently lost coverage for procedural reasons. States can provide MCOs monthly termination files to enable plans to conduct outreach to individuals terminated from Medicaid for procedural reasons (e.g., not returning renewal forms timely). CMS notes states may need to expedite review of plan outreach messaging or may want to consider developing standard language to be used by Medicaid managed care plans to ensure compliance with federal marketing requirements as well as any state-specific laws or contract requirements that may apply. Within two months or less after Medicaid coverage loss, managed care contracts must provide for automatic re-enrollment into an enrollee’s original plan. However, during the PHE unwinding period, CMS will approve state waivers to extend this automatic re-enrollment period up to 120 days.
• Permitting plans to assist individuals to transition to and enroll in ACA Marketplace coverage if ineligible for Medicaid or CHIP. States may encourage MCOs that also offer a Qualified Health Plan (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. CMS notes that federal Medicaid managed care marketing rules (and Exchange regulations) do not prohibit Medicaid managed care plans that offer a QHP from providing information about the QHP to enrollees who could potentially enroll in the QHP due to loss of eligibility; however, plans must comply with state-specific laws and/or contract requirements that may prohibit this activity.

In addition to strategies identified in the CMS guidance, Medicaid managed care plans may also consider adding staff to help manage the unwinding process. Additional staff could work proactively to identify members at-risk for disruptions in care and disenrollment (e.g., individuals with limited English proficiency, people with disabilities). Managed care plans can also work in partnership with providers (including community health centers) and community-based organizations to further bolster efforts to reach and assist members to ensure coverage retention or transitions to Marketplace coverage.

What to watch?

Understanding how managed care plans are involved in the development of state unwinding operational plans and what is included in the operational plans themselves will be key areas to watch. When continuous enrollment requirement ends, states will begin processing renewals and redeterminations and millions of people could lose coverage if they are no longer eligible or face administrative barriers during the process 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 coverage loss related to procedural errors. 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 renewals or redeterminations.

As mid-April approaches, additional information about the timing of the end of the PHE may become available. The Biden administration indicated it would give states 60 days-notice before the PHE is terminated or is allowed to expire. The current PHE is set to expire in mid-April. On February 8, 2022, the Medicaid Health Plans of America (MHPA), a national trade association representing more than 130 MCOs, sent a letter to Congressional leaders asking Congress to provide at least 120-days lead time before the end of the continuous enrollment requirement. States are developing unwinding operational plans but it is not clear that these plans will be made publicly available. The policies adopted and the implementation of strategies to promote continuity of coverage will vary across states and plans and will have major implications for Medicaid and broader coverage as the PHE unwinds.

President Biden recently signed the reauthorization of the Violence Against Women Act (VAWA). The new VAWA includes changes that could help strengthen and expand the availability of health care services for victims, including better oversight of programs for survivors of sexual assault and a new public website with information about the availability of forensic nurse examiners.

To qualify for federal grants to address violence against women, states are required to ensure that rape kits, or Medical Forensic Exams (MFE), are provided at no cost to survivors. However, there are often gaps in coverage for health care services that are outside of the MFE, like sexually transmitted infection testing, emergency contraception, or services for injuries incurred during sexual assault (such as stitches). Coverage policies for these services vary by state and are not necessarily guaranteed to be provided without cost-sharing. While the 2022 VAWA makes many changes, it does not specifically address out-of-pocket charges that many can face after a sexual assault.

In the United States, more than one in three women experience sexual violence in their lifetime. Despite the intent of Violence Against Women Act (VAWA) to protect survivors from out-of-pocket spending stemming from rape kit collection services also known as a medical forensic exam (MFE), many women face health care bills because they seek those critical services.

A new KFF analysis of a sample of private insurance claims from large employers finds that two-thirds (66%) of insured women who received a rape kit after a sexual assault faced out-of-pocket charges for these services, spending an average of $347 out of pocket.

This new analysis also reviews the federal and state policies that contribute to the gaps in coverage for these women, despite the intention of the VAWA to make no-cost rape kits accessible to all survivors.

President Biden recently signed the newly reauthorized VAWA, which does not specifically address the issue of out-of-pocket charges that many face for minimum covered services of the MFE. The reauthorization could help strengthen and expand the availability of health care services for victims, including better oversight and transparency regarding programming for survivors of sexual assault and a new public website with information about the availability of forensic nurse examiners.