Payer Hierarchy: Medicare
- Medicare is the primary payer for most Medicare covered testing for beneficiaries enrolled in Medicare, including Medicare-Medicaid dually eligible individuals.
- For dually eligible individuals, Medicaid may cover additional testing (beyond what is covered by Medicare) based on Medicaid policy. There are some uncommon instances where Medicare could be the secondary payer for a Medicare covered service, discussed here:
- Medicare covers the following diagnostic viral testing for nursing home residents and patients:
- Testing residents with signs or symptoms of COVID-19
- Testing asymptomatic residents with known or suspected exposure to an individual infected with SARS-CoV-2 including close and expanded contacts (e.g., there is an outbreak in the facility)
- Initial (baseline) testing of asymptomatic residents without known or suspected exposure to an individual infected with SARS-CoV-2 as part of the recommended reopening process
- Testing to determine resolution of infection Medicare coverage is consistent with the CDC Testing Guidelines for Nursing Homes, Diagnostic Testing section, available here:
- Medicare does not cover non-diagnostic tests (i.e., testing done for public health surveillance purposes).
- Given that conditions and circumstances may be similar in some other congregate living settings, such as intermediate care facilities for individuals with intellectual disabilities, assisted living facilities, and group homes, Medicare Administrative Contractors have the discretion to apply the coverage and payment criteria for nursing homes to other appropriate settings during the public health emergency.
- Medicare will make payment for one diagnostic test per resident/patient without an order from a physician, practitioner, pharmacist, or other authorized health care professional. All subsequent tests require such an order.
- States should contact the Contractor Medical Directors at their local MAC for specific guidance on coverage and payment for Medicare services. Contact information for the Medicare A/B Contractor Medical Directors for each jurisdiction is here:
Payer Hierarchy: Medicaid and the Uninsured
- Providers should contact the state Medicaid agency and/or contracted Medicaid managed care plan for information on testing coverage, payment, and coding for Medicaid beneficiaries. Medicaid pays after most other payers.
- The Families First Coronavirus Response Act (FFCRA) (Public Law No. 116-127), and Coronavirus Aid, Relief, and Economic Security (CARES) Act (Public Law No. 116-136), added a new optional Medicaid eligibility group for uninsured individuals, effective March 18, 2020. Individuals eligible for the new group (“COVID-19 testing group”) receive a limited benefit package of services related to testing and diagnosis of COVID-19 that are rendered during the public health emergency period.
- Additional information on eligibility, covered benefits, and federal medical assistance percentage (FMAP) for the new COVID-19 testing group is available here: https://www.medicaid.gov/state-resource-center/downloads/covid-19-section-6008-CARES-faqs.pdf and here: https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf
Health Resources and Services Administration (HRSA) COVID-19 Claims Reimbursement to
Health Care Providers and Facilities Testing and Treatment of the Uninsured Program
- This program provides reimbursement directly to eligible providers for COVID-19 testing and treatment services furnished to uninsured individuals. Reimbursement is generally made at the Medicare payment rate.
- To access these funds, providers must enroll in the program as a provider participant, sign the terms and conditions of the program, check patient eligibility, and submit patient information. Once they have done so, they can submit claims for direct reimbursement for COVID-19 testing and treatment services furnished to uninsured individuals on or after February 4, 2020.
- Providers must verify and attest that to the best of the provider’s knowledge at the time of claim submission, the patient was uninsured at the time the services were provided. If the provider subsequently receives reimbursement for any items from other coverage, the provider must return the payment that duplicates other reimbursement to HRSA.
- Individuals who are enrolled in a state’s Medicaid program under the new optional Medicaid COVID-19 testing group are not considered uninsured for purposes of provider payment of COVID-19 testing services through this HRSA program. However, providers can attest to the HRSA program terms and conditions for COVID-19 treatment services provided to individuals enrolled in the new optional Medicaid COVID19 testing group.
- Additional information is available here: https://www.hrsa.gov/coviduninsuredclaim/frequently-asked-questions
- Section 6001 of the Families First Coronavirus Response Act (FFCRA) generally requires group health plans and health insurance issuers to provide benefits for certain items and services related to testing for the detection or the diagnosis of COVID-19 when those items or services are furnished on or after March 18, 2020, and during the public health emergency.
- Under FFCRA, plans and issuers must provide this coverage without imposing any cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management requirements.
- Section 3201 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act amended section 6001 of the FFCRA to include a broader range of diagnostic tests that plans and issuers must cover without any cost-sharing requirements, prior authorization, or other medical management requirements. Section 3202(a) of the CARES Act generally requires plans and issuers providing coverage for these items and services to reimburse any provider of COVID-19 diagnostic testing an amount that equals the negotiated rate or, if the plan or issuer does not have a negotiated rate with the provider, the cash price for such service that is listed by the provider on a public website. (The plan or issuer may negotiate a rate with the provider that is lower than the cash price.)
- Additionally, during the public health emergency, section 3202(b) of the CARES Act requires providers of diagnostic tests for COVID-19 to make public the cash price of a COVID-19 diagnostic test on the provider’s public internet website or face potential enforcement action including civil monetary penalties.
- Health insurance issuers and group health plans must cover COVID-19 diagnostic testing as determined medically appropriate by the individual’s health care provider, consulting CDC guidelines as appropriate.
- Health insurance issuers and group health plans are not required to cover non-diagnostic tests (i.e., testing done for public health surveillance purposes) without cost-sharing. Additional information is available here, including information on which tests are required to be covered:
Additional Funding Sources
CDC Preparedness and Response Supplemental Funding, and CARES Act Funding Distribution to States and Localities in Support of COVID-19 Response
- The Centers for Disease Control and Prevention (CDC) awarded funds and provided guidance to state and local jurisdictions to help them access this funding through existing cooperative agreement mechanisms.
- Jurisdictions may use this funding for a variety of activities including:
- Enhancing testing capacity.
- Establishing or enhancing the ability to aggressively identify cases, conduct contact tracing and follow up, as well as implement appropriate containment measures.
- Controlling COVID-19 in high-risk settings and protect vulnerable or high-risk populations.
- Improving morbidity and mortality surveillance.
- Working with healthcare systems to manage and monitor system capacity.
- Additional information is available here: https://www.hhs.gov/about/news/2020/04/23/updated-cdc-funding-information.html
Provider Relief Fund
- HHS is making payments to facilities and providers to provide financial relief in response to the COVID-19 pandemic.
- Funds must be used for increased healthcare related expenses or lost revenue attributable to coronavirus. They may not be used for expenses or lost revenue that have been reimbursed from other sources or that other sources are obligated to reimburse.
- This funding is for a broad range of unreimbursed expenses, and does not change Medicare or Medicaid coverage or coordination of benefits.
- Additional information on eligibility, payment formulas, and distribution timeline, is available here: https://www.hhs.gov/coronavirus/caresact-provider-relief-fund/index.html
Medicare Coding and Billing
Key Medicare Clinical Lab Fee Schedule (CLFS) Codes
- 87426 (Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative, multiple-step method; severe acute respiratory syndrome coronavirus (eg, SARS-CoV, SARS-CoV-2 [COVID-19])
- P9603 (Per mile travel allowance)
- P9604 (Per Flat-Rate Trip Basis Travel Allowance)
- G2023 (Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), any specimen source)
- G2024 (Specimen collection for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), from an individual in a skilled nursing facility or by a laboratory on behalf of a home health agency, any specimen source)
- Information on additional COVID-19 test codes and pricing is available here: https://www.cms.gov/files/document/mac-covid-19-testpricing.pdf
- CLIA and coding guidance: https://www.cms.gov/files/document/admin-info-20-06-clia.pdf
This document was financed at U.S. taxpayer expense and will be posted on the CMS website.