AHCA: COVID-19 – Update #7

Lisa Volk and Jackie Pappalardi in Clinical & Quality

CMS Releases COVID-19 Medicare FFS and Medicare Advantage Plan Guidance 

The Centers for Medicare & Medicaid Services (CMS) has released COVID-19 Medicare fee-for-service (FFS) and third-party payer guidance - specifically to Medicare Advantage plans. A summary of each is below, as well as hyperlinks to CMS materials. Additionally, America's Health Insurance Plans (AHIP) and the Association for Community Affiliated Plans (ACAP) have both posted plan-by-plan information on their members' COVID-19 coverage changes. 

Medicare FFS COVID-19 Testing Reimbursement

Medicare Part B covers medically necessary clinical diagnostic laboratory tests when a doctor or other practitioner orders them. CMS developed two Healthcare Common Procedure Coding System (HCPCS) codes to bill Medicare Part B for COVID-19 testing: U0001 and U0002. Medicare claims processing systems will accept both codes beginning April 1, 2020, for dates of service on or after February 4, 2020.  

It is important to note that local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates. A longer discussion of Medicare FFS COVID-19 reimbursement is available here.  

CMS Guidance to Medicare Advantage Plans

CMS yesterday issued guidance to Medicare Advantage (MA) and Part D plans outlining plan options and plan requirements. New and current flexibilities available to plans are intended to break down barriers to beneficiary access to care.

  1. Plans may offer access to Medicare Part B services via telehealth in any geographic location and from a variety of places including a beneficiaries' home.
  2. Plans may choose to waive plan prior authorization requirements that otherwise would apply to test or services related to COVID-19 at any time.

The CMS memo also reviews the special requirements MA plans must adhere to in a disaster or emergency, including:

  1. Cover plan benefits furnished at non-contracted facilities (e.g. out-of-network providers);
  2. Waive, in full, requirements for gatekeeper referrals where applicable; 
  3. Provide same cost sharing for the enrollee as if services were received in a contracted facility; and
  4. Make changes that benefit the beneficiary without the 30-day notification requirement (such changes could include reductions in cost). 

Lastly, CMS reminded MA plans that under a specific emergency waiver authority (known as a Katrina Waiver), the agency may authorize MACs to pay for Part C covered services furnished to beneficiaries enrolled in MA plans and retrospectively seek reimbursement from the MA plan for those services. Providers should check with their participating MA plans to understand which flexibilities the plan offers. The CMS guidance memo is available here

Health Plan Information

On Tuesday, AHIP issued an industry response statement to COVID-19. It has also compiled a helpful list of specific health insurance plans' responses to COVID-19 regarding services and benefits: Health Insurance Providers Respond to Coronavirus (COVID-19) - AHIP. The responses may differ among health plans and include measures such as:

  • Waiving co-pays for diagnostic testing related to COVID-19; 
  • Waiving co-pays and out-of-pocket costs for emergency and urgent care services; 
  • No-cost telemedicine visits; 
  • Waiving some prior authorization requirements; 
  • Waiving prescription refill limits; and 
  • Providing additional stress and anxiety support services. 

AHIP has also developed a COVID-19 Resource Center. AHCA/NCAL recommends providers contact each of their health insurance plans for policies and procedures (or changes to existing policies and procedures) for COVID-19 related and non-related admissions and residents. 

Finally, as mentioned, ACAP (the not-for-profit Medicaid and Medicare-Medicaid health plan association) also has posted an array of COVID-19 resources on plan coverage. No other health plan associations have posted coverage information to-date. 

AHCA/NCAL will provide weekly COVID-19 reimbursement and market coverage updates. Please email COVID19@ahca.org with any questions or comments.

NYSHFA/NYSCAL CONTACTS:

Carl J. Pucci
Chief Financial Officer
518-462-4800 x36

Lisa Volk, RN, B.P.S., LNHA
Director, Clinical & Quality Services
518-462-4800 x15