Update from MedCost on the Coronavirus (COVID-19) Emergency

Testing

After May 11, 2023:  
Mandatory coverage for over-the-counter (OTC) and laboratory-based COVID-19 PCR and antigen tests will end. Plans may choose to cover these tests but may require cost sharing, prior authorization, or other forms of medical management. Plans also may choose to cover COVID-19 testing the same as all other laboratory tests.

Through May 11, 2023: The Families First Coronavirus Response Act (FFCRA) requires all group health plans and health insurers, including grandfathered health plans under the ACA, to cover testing for COVID-19 without any cost sharing (co-pays, co-insurance, deductibles). The Coronavirus Aid, Relief, and Economic Security Act (CARES ACT) confirmed that this requirement applies to both in- and out-of-network services.

Effective January 15, 2022, the federal government expanded this coverage by requiring health plans and insurers to cover FDA-authorized at-home over the counter (OTC) COVID-19 diagnostic tests without cost-sharing and issued guidance to help clarify how plan participants may seek reimbursement for the tests during the remainder of the ongoing public health emergency. 

Many pharmacy benefit managers (PBM) are allowing health plan members to purchase FDA-authorized OTC COVID-19 test kits as part of their pharmacy benefit at retail pharmacies with no upfront cost to the member and no need to submit for reimbursement. Although the PBMs are implementing this change immediately, there may be a transitional period while each individual merchant (pharmacy) updates their systems. Because each merchant will adhere to their own timeline, this may result in inconsistencies in shopping experiences (i.e., test kits may be purchased at no upfront cost at one location but require payment at another). You may want to contact your pharmacy to see if they are prepared to submit the test kit to your pharmacy plan for coverage. If you are asked to pay upfront for an OTC test, please save your receipt and contact the PBM shown on your health plan ID card for reimbursement.  

The following provides a general overview of how to get your OTC COVID-19 test for free.* To ensure you have the most current and accurate information, we encourage you to contact or visit the website of the PBM shown on your health plan ID card. 

1. Visit a pharmacy as designated by your assigned PBM.  
2. Choose an FDA-authorized OTC antigen test kit. This list is continually being updated as testing products receive Emergency Use Authorization (EUA) clearance. Some of the most common tests include, but are not limited to, BinaxNOW™, Flowflex™, InteliSwab™, On/Go™, Ellume™, and QuickVue®.
3. Present your health plan ID card at the pharmacy counter and ask to have your test kit submitted to your pharmacy plan for coverage. A prescription is not required to obtain test kits, but there is a quantity limit of 8 units/tests per covered member per calendar month/30-day period if purchased without a prescription. 
4. If your doctor gave you a prescription for an OTC at-home COVID-19 test kit, submit it to your in-network pharmacy just as you would any other prescription. This also should be available at no cost. Quantity limits do not apply to at-home test kits prescribed by your doctor.
5. If you are charged for an FDA-authorized OTC test kit at a pharmacy, or you purchased a test kit online or at a non-pharmacy retail location, SAVE YOUR RECEIPT. You will need it to file a claim for reimbursement. To submit a claim for reimbursement, contact or visit the website of the PBM shown on your health plan ID card (see below for a list of PBMs commonly used by MedCost employer groups). 

*If you pay upfront for a test kit, you will be reimbursed up to $12 per test/unit (or the cost of the test, if less than $12). To be eligible for reimbursement, an at-home test must have a purchase date of 1/15/22 or later and must be FDA-authorized. If you plan to seek reimbursement under your pharmacy benefit as described above, you cannot use your FSA/HSA card to purchase these tests. You will be asked to pay for shipping if you place orders for home delivery of kits. The cost of test kits will not apply to member deductibles. No additional utilization management edits (i.e., prior authorization or other limits) will be applied.

Some PBMs have information regarding reimbursement for at-home COVID test kits available online:

• CVS Caremark  
• Maxor+     
• Navitus     
• OptumRx     
• SmithRx     
• Southern Scripts     
   

Note: Testing conducted to screen for general workplace health and safety (such as employee “return to work” programs), for public health surveillance, or for any other purpose not primarily intended for individualized diagnosis or treatment is excluded from these requirements.

Treatment 

After May 11, 2023:

Plans that require cost sharing or apply deductibles for COVID-19 treatments may continue to do so.

Through May 11, 2023: Treatment for COVID-19 was not addressed by FFCRA or the CARES Act. All medical plans administered by MedCost include coverage for treatment (in office and, if covered, virtual) of COVID-19. Treatment is generally subject to normal cost-sharing (co-pays, co-insurance, deductibles), but a small number of MedCost administered plans offer enhanced benefits for COVID-19 treatment. Log in to check your plan’s summary plan description for coverage information.

Further details are available in MedCost Medical Policy #101 – COVID 19 Testing and Treatment. To view, please log in to the secure Members portal. 

After May 11, 2023:

Mandatory coverage of all COVID vaccines as required by COVID-era legislation will end. Non-grandfathered plans, however, will be required under the Affordable Care Act’s (ACA) preventive services coverage mandate to continue to cover in-network COVID-19 vaccines, including booster doses, without cost sharing. Out-of-network vaccine coverage will no longer be required.

Through May 11, 2023: If your health plan is non-grandfathered (as most now are), coverage for COVID-19 vaccine(s) is automatic, as required by the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). The vaccine is included under preventive care and covered in-network at 100% with no cost-sharing. 

Grandfathered health plans, on the other hand, are not required to cover the vaccine, but many already cover preventive vaccinations (which now includes COVID-19) in-network at 100% with no cost-sharing. Log in and check your plan’s benefits summary for coverage information.

As of July 10, 2023:

The regulations requiring health plans to extend certain deadlines related to special enrollment periods, COBRA continuation coverage, claims filing, and appeals due to the COVID-19 National Emergency were calculated based on the “outbreak period”—beginning March 1, 2020, and extending until 60 days following the announced end of the national emergency. Therefore, as of July 10, 2023, all the deadlines will revert to their original timeframes as prescribed by each individual regulation.

Through July 9, 2023: The U.S. Department of Labor and the Internal Revenue Service have issued a regulation that requires health plans to extend certain deadlines related to special enrollment periods, COBRA continuation coverage, claims filing, and appeals, due to the COVID-19 National Emergency. Below is a more detailed overview of the deadlines impacted.  

Deadlines Impacted 

The following deadlines will revert to their normal pre-COVID timelines as of July 10, 2023:

Special Enrollment Periods  

• The 30-day special enrollment periods that may be triggered when eligible employees or dependents lose eligibility for other health plan coverage in which they were previously enrolled, and when an eligible employee acquires a dependent through birth, marriage, adoption, or placement for adoption; and  
• The 60-day special enrollment periods that may be triggered by changes in eligibility for state premium assistance under the Children’s Health Insurance Program. 

COBRA  

• The 30- or 60-day deadline for employers or individuals to notify the plan of a qualifying event;  
• The 60-day deadline for individuals to notify the plan of a determination of disability;
• The 14-day deadline for plan administrators to furnish COBRA election notices;  
• The 60-day deadline for participants to elect COBRA; and  
• The 45-day deadline in which to make a first premium payment and 30-day deadline for subsequent premium payments. 

Claims Procedures and Appeals for ERISA Plans  

• Deadlines for filing claims for benefits and for initial disposition of claims; and 
• Deadlines for providing claimants a reasonable opportunity to appeal adverse benefit determinations under ERISA plans and non-grandfathered group health plans.  

External Review Process  

• Non-grandfathered group health plan deadlines for providing the required state or federal external review process following exhaustion of the plan’s internal appeals procedures; and  
• Other deadlines that apply for perfecting an incomplete request for review. 

Claims Filing Deadlines

Claims filing deadlines can vary by payer/administrator and can also be dictated by requirements within individual health plans, ranging from 90 days to 18 months. The majority of payers/administrators leasing our networks (MedCost Network and MedCost Virginia) offer a generous 180-day claims filing deadline. Plans administered by MedCost Benefit Services, our own TPA, also offer a claims filing deadline of at least 180 days. Certain deadlines affecting filing claims for benefits, appeals of denied claims, and external review of certain claims are automatically extended during the COVID-19 outbreak. Please see Deadline Extensions for Special Enrollment Periods, COBRA, Claim Filing and Appeals for details. As always, MedCost Benefit Services will work closely with providers, clients and health plan members to evaluate additional flexibility and special considerations as needed during the COVID-19 health emergency. Other payers/administrators accessing MedCost Network and MedCost Virginia as leased networks will have their own procedures or policies in place. If you have specific questions, please direct them to the payer/administrator indicated on the back of the member’s ID card. 

Claim Filing Recommendations

Diagnosis or Treatment

To ensure appropriate flagging of COVID-19 related care, and in accordance with CMS guidelines, we recommend institutional claims for COVID-19 diagnosis or treatment include condition code “DR.”

Claims processing procedures for COVID-19 testing related services have been amended for plans administered by MedCost Benefit Services. Effective for dates of service on or after September 1, 2020, providers must submit appropriate coding for COVID-19 testing related services for any claim submission. This requires the use of modifier CS in the first position on any COVID-19 related services that result in an order or administration of a COVID test. This may include but is not limited to physician office visits, labs, or diagnostic imaging, as described in the MedCost Benefit Services Medical Policy. The actual COVID-19 test does not require the use of the modifier. The modifier should only be used for services when determining if a COVID-19 test is required. Using the appropriate modifier ensures that correct benefits are applied.  Please refer to the MedCost Benefit Services Medical Policy for more detailed information. 

Vaccinations

MedCost encourages providers to file COVID vaccination claims based on the American Medical Association (AMA) recommendations. Claims for COVID vaccines will process under a specific employer group plan based on their benefits, as any other vaccine would. Claims filed with incorrect codes will be denied.

Filing a Telehealth Claim

It is up to the plan sponsor (employer or insurance carrier) to elect to cover telehealth visits (COVID-19 and non-COVID-19) under their health plan and also whether to waive applicable cost-sharing (co-pays, co-insurance, deductibles). To verify coverage and/or any applicable cost sharing for telehealth services or for other specific questions, please contact the payer/administrator indicated on the back of the member’s ID card.

MedCost Network and MedCost Virginia have allowables established for telehealth services. To ensure accurate pricing and payment consideration, telehealth services should be accurately coded to reflect the means of delivery ensuring medically necessary services are appropriately filed following these guidelines: 

Professional services (HCFA filers): File with place of service “02” to signify telehealth using applicable telehealth service codes. Modifier “95” is accepted if filed but is not required, and it is recommended that audio and telephonic services (when secure video function cannot be used) are filed with modifier “CR” appended (catastrophe/disaster related). 

Facility services (UB filers): File with the corresponding revenue code for the services being performed. Modifier “95” is required to be appended to all telehealth CPT and HCPCS codes. 

For COVID-19 related services, please ensure your claim is filed with the appropriate COVID-19 diagnosis code(s). 

Services delivered via telemedicine should not be billed as though the service was provided in person. MedCost reserves the right to audit for coding accuracy and may deny claims or seek reimbursement for improperly coded claims.

After May 11, 2023:

Mandatory coverage of all COVID vaccines as required by COVID-era legislation will end. Non-grandfathered plans, however, will be required under the Affordable Care Act’s (ACA) preventive services coverage mandate to continue to cover in-network COVID-19 vaccines, including booster doses, without cost sharing. Out-of-network vaccine coverage will no longer be required.

If you have specific questions regarding a health plan’s coverage for COVID-19 vaccination, please direct them to the payer/administrator indicated on the back of the member’s ID card. Claims for COVID-19 vaccination should be filed as any other preventive vaccination using the appropriate service code(s). 

Through May 11, 2023: Non-grandfathered health plans under the ACA are required to cover COVID-19 vaccine(s) in-network at 100% with no cost-sharing. Grandfathered health plans are not required to cover the vaccine, but many already cover preventive vaccinations (now including COVID-19) in-network at 100% with no cost-sharing. 

If you have specific questions regarding a health plan’s coverage for COVID-19 vaccination, please direct them to the payer/administrator indicated on the back of the member’s ID card. Claims for COVID-19 vaccination should be filed as any other preventive vaccination using the appropriate service code(s). 

See Claims Filing section of this webpage for vaccine filing information based on AMA recommendations.

Testing

After May 11, 2023:

Mandatory coverage for over-the-counter (OTC) and laboratory-based COVID-19 PCR and antigen tests will end. Plans may choose to cover these tests but may require cost sharing, prior authorization, or other forms of medical management. Alternatively, plans may choose to cover COVID-19 testing the same as all other laboratory tests.

IRS Notice 2020-15 allowed plan sponsors to voluntarily cover COVID-19 testing under a high deductible health plan (HDHP) without participant cost-sharing without jeopardizing the HSA eligibility of plan participants enrolled “until further guidance is issued.” To date, there has been no indication that this relief will end due to the ending of the PHE. Thus, HDHPs can continue to provide coverage in this manner without jeopardizing HSA-eligibility until further notice

Through May 11, 2023: All medical plans for MedCost Benefit Services clients include coverage for testing and treatment of COVID-19. The Families First Coronavirus Response Act requires all group health plans and health insurers, including self-funded and grandfathered health plans under the ACA, to cover testing for COVID-19 without any cost sharing (co-pays, co-insurance, deductibles). The language of the bill does not limit this requirement to in-network services. On April 11, 2020, several federal agencies clarified that this requirement extends to serological (antibody) tests that otherwise meet the requirements for coverage. Effective January 15, 2022, the federal government expanded this coverage by requiring health plans and insurers to cover FDA-authorized at-home over the counter (OTC) COVID-19 diagnostic tests without cost-sharing during the remainder of the ongoing public health emergency. Many pharmacy benefit managers (PBMs), including those commonly used by MedCost employer groups, are allowing health plan members to purchase FDA-authorized OTC COVID-19 test kits at retail pharmacies as part of their pharmacy benefit with no upfront cost to the member and no need to submit for reimbursement. Although PBMs are implementing this change immediately, there may be a transitional period while each individual merchant (pharmacy) updates their systems. Members should contact their PBM for questions about reimbursement. (To be eligible for reimbursement, an at-home test must have a purchase date of 1/15/22 or later and must be FDA-authorized.) A prescription is not required to obtain test kits, but there is a quantity limit of 8 units/tests per covered member per calendar month/30-day period if purchased without a prescription. Prescriptions for OTC at-home COVID-19 test kits should be submitted to an in-network pharmacy just as any other prescription. Quantity limits do not apply to at-home test kits prescribed by a provider.

On June 23, 2020, several federal agencies clarified that testing conducted to screen for general workplace health and safety (such as employee “return to work” programs), for public health surveillance, or for any other purpose not primarily intended for individualized diagnosis or treatment is beyond the scope of the FFCRA and CARES ACT requirements.

Treatment 

After May 11, 2023:

The end of the PHE will not change how COVID-19 treatments are covered; plans that require cost sharing or apply deductibles may continue to do so.

IRS Notice 2020-15 allowed plan sponsors to voluntarily cover COVID-19 treatment under a high deductible health plan (HDHP) without participant cost-sharing without jeopardizing the HSA eligibility of plan participants enrolled “until further guidance is issued.” To date, there has been no indication that this relief will end due to the ending of the PHE. Thus, HDHPs can continue to provide coverage in this manner without jeopardizing HSA-eligibility until further notice.

Through May 11, 2023: The Families First Coronavirus Response Act does not address treatment for COVID-19. However, all medical plans for MedCost Benefit Services clients include coverage for treatment of COVID-19, which is covered subject to normal cost-sharing. Health plan sponsors who choose to do so may waive applicable cost-sharing (co-pays, co-insurance, deductibles) for the treatment of COVID-19.

The IRS has declared that HSA-eligible High Deductible Health Plans are permitted (but not required) to cover COVID-19 testing and treatment before cost-sharing without impacting HSA status. 

As of July 10, 2023:

The regulations requiring health plans to extend certain deadlines related to special enrollment periods, COBRA continuation coverage, claims filing, and appeals due to the COVID-19 National Emergency were calculated based on the “outbreak period”—beginning March 1, 2020, and extending until 60 days following the announced end of the national emergency. Therefore, as of July 10, 2023, all the deadlines will revert to their original timeframes as prescribed by each individual regulation.

Through July 9, 2023: The U.S. Department of Labor and the Internal Revenue Service have issued a regulation that requires health plans to extend certain deadlines related to special enrollment periods, COBRA continuation coverage, claims filing, and appeals, due to the COVID-19 National Emergency. Below is a more detailed overview of the deadlines impacted.  

Deadlines Impacted 

The following deadlines will revert to their normal pre-COVID timelines as of July 10, 2023:

Special Enrollment Periods  

• The 30-day special enrollment periods that may be triggered when eligible employees or dependents lose eligibility for other health plan coverage in which they were previously enrolled, and when an eligible employee acquires a dependent through birth, marriage, adoption, or placement for adoption; and  
• The 60-day special enrollment periods that may be triggered by changes in eligibility for state premium assistance under the Children’s Health Insurance Program. 

COBRA  

• The 30- or 60-day deadline for employers or individuals to notify the plan of a qualifying event;  
• The 60-day deadline for individuals to notify the plan of a determination of disability;
• The 14-day deadline for plan administrators to furnish COBRA election notices;  
• The 60-day deadline for participants to elect COBRA; and  
• The 45-day deadline in which to make a first premium payment and 30-day deadline for subsequent premium payments. 

Claims Procedures and Appeals for ERISA Plans  

• Deadlines for filing claims for benefits and for initial disposition of claims; and 
• Deadlines for providing claimants a reasonable opportunity to appeal adverse benefit determinations under ERISA plans and non-grandfathered group health plans.  

External Review Process  

• Non-grandfathered group health plan deadlines for providing the required state or federal external review process following exhaustion of the plan’s internal appeals procedures; and  
• Other deadlines that apply for perfecting an incomplete request for review. 

It is up to the plan sponsor (employer or insurance carrier) to elect to cover telehealth visits (COVID-19 and non-COVID-19) under their health plan and also whether to waive applicable cost-sharing (co-pays, co-insurance, deductibles). To verify coverage and/or any applicable cost sharing for telehealth services or for other specific questions, please contact the payer/administrator indicated on the back of the member’s ID card.

Filing a Telehealth Claim

MedCost Network and MedCost Virginia have allowables established for telehealth services. To ensure accurate pricing and payment consideration, telehealth services should be accurately coded to reflect the means of delivery ensuring medically necessary services are appropriately filed following these guidelines: 

Professional services (HCFA filers): File with place of service “02” to signify telehealth using applicable telehealth service codes. Modifier “95” is accepted if filed but is not required, and it is recommended that audio and telephonic services (when secure video function cannot be used) are filed with modifier “CR” appended (catastrophe/disaster related). 

Facility services (UB filers): File with the corresponding revenue code for the services being performed. Modifier “95” is required to be appended to all telehealth CPT and HCPCS codes. 

For COVID-19 related services, please ensure your claim is filed with the appropriate COVID-19 diagnosis code(s). 

Services delivered via telemedicine should not be billed as though the service was provided in person. MedCost reserves the right to audit for coding accuracy and may deny claims or seek reimbursement for improperly coded claims.