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

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

Medicare will continue to pay an additional amount of about $36 in addition to regular administration fees for the administration of COVID-19 vaccines at home when the PHE ends. This additional Medicare payment for at-home COVID-19 vaccinations will continue through the end of calendar year 2023. For individuals enrolled in a MA plan, provider payment rates are determined by the contract between the MA plan and the provider when such a contract is in place and may or may not include additional payments for at-home COVID-19 vaccinations. If there is no contract in place for vaccinations covered by the MA plan, the Medicare payment rate would apply.

Yes. There is no change in Medicare coverage of treatments for those exposed to COVID-19 once the PHE ends, and in cases where cost sharing and deductibles apply now, they will continue to apply. Generally, the end of the COVID-19 PHE does not change access to oral antivirals, such as Paxlovid and Lagevrio. For individuals enrolled in a MA plan, the plans must cover treatments that Traditional Medicare covers (with some exceptions), but they may require the individual to see a provider who is in the MA plan’s network and may have different cost sharing than Traditional Medicare.

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

Yes, in most cases. During the PHE, individuals with Medicare had broad access to telehealth services, including in their homes, without the geographic or location limits that usually apply. These waivers were included as provisions of The Consolidated Appropriations Act, 2023, which extended many telehealth flexibilities through December 31, 2024, such as: • People with Medicare can access telehealth services in any geographic area in the United States, rather than only in rural areas. • People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility. • Certain telehealth visits can be delivered using audio-only technology (such as a telephone) if someone is unable to use both audio and video (such as a smartphone or computer).
However, if an individual receives routine home care via telehealth under the hospice benefit, this flexibility will end at the end of the PHE. MA plans may offer additional telehealth benefits. Individuals in an MA plan should check with their plan about coverage for telehealth services. Additionally, after December 31, 2024, when these flexibilities expire, some ACOs may offer telehealth services that allow primary care doctors to care for patients without an in-person visit, no matter where they live.

CMS is exercising enforcement discretion to allow teaching physicians in all teaching settings to be present virtually, through audio/video real-time communications technology, for purposes of billing under the PFS for services they furnish involving resident physicians. We are exercising this enforcement discretion through December 31, 2023, as we anticipate considering our policy for services involving teaching physicians and residents further through our rulemaking process.

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

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

Nothing. As is currently the case during the PHE, coverage for telehealth and other remote care services will vary by private insurance plan after the end of the PHE. When covered, private insurance may impose cost-sharing, prior authorization, or other forms of medical management on telehealth and other remote care services. For additional information on your insurer’s approach to telehealth, contact your insurer’s customer service number located on the back of your insurance card.