President Biden’s announcement that the Covid-19 public health emergency (PHE) will end on May 11 will have a significant impact on older adults. Some changes will be immediate, others won’t occur for nearly two years. Some may improve care for older adults, others could cost seniors more money and end some important benefits they received during the pandemic.

Biden’s decision buys a few more months under the emergency. Hill Republicans had been pressuring the Administration to end the PHE even sooner.

The most immediate loss will be the return of the so-called three-day rule. The most far-reaching could be sharp reductions in Medicare payments for telehealth services and loss of Medicaid benefits for many. Here is just some of what will change:

Medicare’s three-day rule. Prior to the health emergency, Medicare would pay for post-acute care in a skilled nursing facility (SNF) only if a beneficiary first had been admitted to a hospital for at least three days. That requirement became the subject of enormous confusion by seniors and frustration by nursing homes and hospitals that were being blamed for rules not of their making.

For example, someone being cared for in a hospital, but under observation status, was not considered admitted and thus did not satisfy the three-day rule. Even if they were in a hospital bed for three days under the care of a hospital doctor and nurse. Separate Medicare rules severely penalize hospitals that admit patients who, after review, are determined to be eligible only for an observation stay.

Once the PHE ends, the three-day rule returns. Once again, Medicare beneficiaries will have to pay for costly skilled nursing care out of their own pockets unless they first are admitted to a hospital for at least three days.

Telehealth. The use of virtual telehealth medical visits exploded after 2020 in large part because Medicare being paying for the care. An estimated 28 million Medicare beneficiaries had telehealth visits in just the first year of the pandemic.

While Medicare’s broader authority to pay for telehealth expires 151 days after the PHE expires (don’t ask), a separate law extends these benefits through 2024. After that, Congress will need if Medicare is going to continue to pay to for telehealth.

Covid-19 treatment. During the PHE, test kits and treatment drugs such as Paxlovid were free to Medicare recipients. Medicare enrollees may now have to pay some costs. Vaccines still will be free.

Discharge planning. Under the emergency, Medicare waived many rules that required hospitals and nursing homes to provide certain discharge information to patients who needed post-acute care. While those rules often were ignored even before the pandemic, the emergency allowed hospitals to provide even less information. Starting in May, they will again have to provide more detailed discharge information to patients and their families.

Nursing homes. Medicare waived a number of staffing and training rules for skilled nursing facilities during the early days of the PHE. Many already have been restored and the rest will return when the emergency ends.

Home health and hospice. Training and assessment programs for aides that were waived during the PHE will be restored. Hospice, which was allowed to drop benefits such as physical and occupational therapy and volunteer visits, will once again have to provide those services.    

Medicaid enrollment: In an effort to make Medicaid more accessible during the pandemic, the federal government increased its contributions to the joint federal/state program. But the money came with a catch: States had to agree to not drop anyone off their Medicaid rolls during the public health emergency.

In May, states will once again be able to drop enrollees who  fail to meet all eligibility requirements. One concern: What will happen to those who don’t receive—or respond to– notices that their eligibility is being reviewed? For example, the mail may not follow an older adult who moves to a nursing home. Or a senior living with dementia may not open mail in a timely way. A separate law allows states to start Medicaid eligibility redeterminations as soon as April 1. The additional federal funding phases out through the rest of this year.

State Medicaid flexibility. Medicaid recipients generally are entitled to long-term care only in nursing homes. States can provide home care benefits only with a waiver from the federal government.

During the pandemic states were granted broad waiver flexibility in the kinds of home-based initiatives they could offer, even if some were not explicitly allowed by law. But that will end with the PHE. Some waiver authorities will disappear immediately, others will expire after 60 days, and still others will continue for an additional six months.

But overall, states will find it more difficult to get the federal OK to expand their Medicaid home and community-based long-term care services.

There will be plenty of other changes, as well. The PHE gave Medicare and Medicaid new flexibility to both improve patient care and ease burdens on providers during extraordinary times. Its demise will change the way older adults get care, for better or worse.