Pay BillCOVID-19 Coronavirus Provider Updates
Coverage and Cost Share Changes Effective May 12
When the COVID-19 federal public health emergency pandemic ends on May 11, 2023, the federally mandated coverage and cost share waivers will end. Therefore, Independent Health’s coverage and cost sharing as of May 12, 2023 for services related to COVID-19 will change.
Commercial, Fully Insured Plans*:
- At-home, over-the-counter COVID-19 tests will no longer be covered by Independent Health after May 11, 2023.
- Lab tests for the diagnosis of COVID-19 and pre-surgical testing for COVID-19 will be covered like other lab tests: depending on the member’s plan there may be a cost share for the COVID-19 lab test, along with the applicable office visit.
The urgent care cost share will apply if members have a diagnostic COVID-19 test at an urgent care center. - Independent Health will continue to cover COVID-19 vaccinations and boosters in full.
*Exception: Members of the Federal Employees Health Benefits Plan (FEHB) will continue to have coverage for at-home, over-the-counter COVID tests. The cost share will be the same as other lab services ($0 or $0 after deductible, depending on the FEHB plan).
Medicare Advantage Plans:
- At-home, over-the-counter COVID-19 tests will no longer be covered by Medicare.
- Lab tests for the diagnosis of COVID-19 will be covered like other lab tests. If a member’s plan covered only COVID-19 lab tests in full, they will now be covered as any other lab test. This includes any pre-surgical testing that is required.
The urgent care cost share will apply if members have a diagnostic COVID-19 test at an urgent care center. - Independent Health will continue to cover COVID-19 vaccinations and boosters in full.
Medicare Medication/Pharmacy changes
- During the COVID-19 pandemic, in certain circumstances members were able to get earlier refills than usual, and in some cases, more than a 30 day supply.
- As of May 12, there may be a return to dispensing policies of 30-day supplies and limitations on how early members can obtain a refill. As it was before the pandemic, there are still processes in place with the pharmacies to contact us in special circumstances.
- Please note that prescriptions already designated for a 90-day supply on our formulary will remain the same.
Medicare Changes as of June 12, 2023
- COVID-19 related treatment at out-of-network providers or facilities will take the out-of-network cost share, according to the member’s benefit plan, as of June 12, 2023.
- These services will no longer take the in-network cost share. If the benefit plan does not have an out-of-network benefit, then the member will be responsible for the cost of the visit.
State Programs
Note: For now, there are no changes to the current coverage for COVID.
Self-funded Plans
Self-funded employers have the choice to follow commercial fully insured plans. In most cases, they will align with the fully insured coverage. As of April 19, there is one plan (National Grid) that will continue covering OTC tests for the time being.
Telehealth and other services
Independent Health is evaluating more permanent coverage and considerations for telehealth, and we will provide more information in the coming weeks once we have updated the Telehealth Services policy.
Covid-19 Vaccination, Coverage and Reimbursement Summary
To stay up-to-date on vaccinations in New York, visit the New York State website.
Cost share and coverage criteria
Independent Health members pay no cost share for Covid-19 vaccination, including the booster shot, for all lines of business:
- Commercial
- Medicare Advantage
- State Programs: (MediSource, Child Health Plus, Essential)
- Self-funded plans*
Providers must not balance bill or seek reimbursement from immunization recipients for the Covid-19 vaccine.
*Grandfathered plans must also cover Covid-19 vaccine and administration fees with no member cost share while the Federal Government is the sole payer for the vaccine.
Independent Health is complying with applicable regulatory guidance in member eligibility for vaccination.
Reimbursement
Medicare Advantage
For claims with dates of service on or after January 1, 2022: Independent Health will begin to cover the vaccine administration cost. Medicare Fee-for-Service will no longer cover the administration cost. Reimbursement rates can be found in the chart below. The vaccine doses will continue to be dispensed under federal and state vaccination plans and are funded by the federal government. The code for the vaccine should not be submitted when you obtain it at no charge.
Additionally, when a provider administers the COVID-19 vaccine to a Medicare Advantage member under certain conditions in their home, the provider is eligible to bill Independent Health for the additional at-home rate under code M0201.
Independent Health follow’s CMS criteria for eligible members which includes:
- The patient has a condition that makes them more susceptible to contracting a pandemic disease such as COVID-19.
- The patient is generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort.
- The patient has a disability or faces clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home.
- The patient faces challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving.
M0201 - Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only covid-19 vaccine administration is performed at the patient's home
Full details on eligibility for billing M0201 are posted here.
For claims with dates of service prior to January 1, 2022: Medicare Fee-for-Service is paying for the vaccine and administration components for all Medicare beneficiaries, including those enrolled in Medicare Advantage plans, through calendar year 2021.
Providers must submit claims to their applicable Medicare Administrative Contractor (MAC) (National Government Services in Western New York) for reimbursement. Members will not receive Explanation of Benefits (EOB) from Independent Health.
Fee Schedule and Coding
Below are the Independent Health rates for Covid-19 vaccine administration.
Fees are effective for the vaccines which have obtained FDA approval.
Visit the CMS site for a comprehensive list of vaccine products, codes and effective dates as the FDA approves them.
COVID-19 Vaccine Administration Rate Chart Effective April 1, 2023
Administration Code* |
Facility Rates All LOBs |
Office Rates Commercial, Medicare & Self-Funded |
Office Rates State Products |
|---|---|---|---|
(1st Dose) |
$40 |
$40 |
$40 |
(2nd Dose) |
$40 |
$40 |
$40 |
(3rd Dose) |
$40 |
$40 |
$40 |
Boosters |
$40 |
$40 |
$40 |
COVID-19 Vaccine Administration Rate Chart Effective June 1, 2023
Administration Code* |
Facility Rates All LOBs |
Office Rates Commercial, Medicare & Self-Funded |
Office Rates State Products |
|---|---|---|---|
(1st Dose) |
$40 |
$38.81 |
$40 |
(2nd Dose) |
$40 |
$38.81 |
$40 |
(3rd Dose) |
$40 |
$38.81 |
$40 |
Boosters |
$40 |
$38.81 |
$40 |
*Bill the administration code that corresponds with the manufacturer, patient age, and dose that is administered.
Coding
- The AMA has released CPT® codes for reporting the vaccine and administration.
- The codes are specific to the manufacturer and dose schedule.
Pharmacy Billing
For COVID-19 vaccines billed after the supply of government-purchased vaccines runs out, pharmacies should bill purchased COVID vaccines to Independent Health using the online NCPDP format.
Reimbursement for vaccines and administration are based on our pharmacy network contracts.
NCPDP D.0 Field |
Value |
|---|---|
436-E1 (Product/Service ID Qualifier) |
“03” (NDC) |
407-D7 (Product/Service ID) |
Enter the 11-digit NDC corresponding to the |
420-DK (Submission Clarification Code) |
Optional (this is no longer a required field)* |
440-E5 (Professional Service Code) |
Enter “MA” (Medication Administration) |
*Submission Clarification Codes to use for COVID Vaccines
Dose |
Submission Clarification Code |
|---|---|
(1st Dose) |
“02” (Other Override) |
(2nd Dose) |
“06” (Starter Dose) |
(3rd Dose) |
“07” (Medically Necessary) |
Boosters |
“10” (Meets Plan Limits) |
If you have questions about this information or experience a billing issue, please call Independent Health’s Pharmacy Help Desk at (716) 631-2927.
Questions?
Contact our Provider Relations Department by phone at (716) 631-3282 or 1-800-736-5771, or email at providerservice@servicing.independenthealth.com, Monday through Friday from 8 a.m. to 6 p.m.
Last Updated 4/28/23