Post-PHE coverage changes for your patients & virtual care billing updates

On May 11, 2023, the COVID-19 public health emergency (PHE) is scheduled to end.

The PHE allowed for member cost share flexibility within their health plan for COVID-19 related claims. The end of PHE will mark several cost share and coverage changes for testing, vaccines and more.

Here’s a summary of the updates that will take place on May 12:

Tests

Diagnostic tests

  • Commercial, Individual/ACA, Medicare: Medically necessary COVID-19 diagnostic tests will return to a lab/ER benefit as appropriate and with applicable copays, coinsurance or deductibles based on a member’s plan type.
  • Medicaid: Medically necessary COVID-19 diagnostic tests will be covered with a $0 cost share through September 2024. After that date, there may be a limit to the number of covered tests or nominal cost-sharing.

OTC (Over the Counter) at-home test kits

  • Commercial, Individual/ACA, Medicare: OTC test kits will no longer be covered.
  • Medicaid: At-home test kits will be covered for free through September 2024. After that date, OTC tests may no longer be covered.

Vaccines

COVID-19 vaccines administered at an in-network provider are covered* as a preventive benefit with $0 member cost share. We’ll no longer cover COVID-19 vaccines administered at an out-of-network provider.

*Exception: Members enrolled in grandfathered and retiree commercial plans should check their plan documents to determine vaccine coverage.

Pharmaceutical treatments

Pharmaceutical COVID-19 treatments will be covered as any other pharmaceutical treatment, with applicable copays, coinsurance or deductibles based on a member’s plan type.

Virtual care

Coverage

Medicare: Virtual care coverage remains the same until December 2024.

Medicaid: Virtual care coverage remains the same.

Commercial, Individual / ACA: Several codes are listed in our Telemedicine medical policy (#91604) as “Temporary additions for the PHE for the COVID-19 pandemic.” After a thorough review, we’ve determined to continue to cover many of these services when performed virtually.

However, coverage for some of these visits performed virtually will end when the PHE ends, including (but not limited to) temporary additions for:

  • Audiometry, evaluation of auditory function for surgically implanted devices and diagnostic analysis of cochlear implant
  • Brief emotional/behavioral assessment with standardized instrument
  • Emergency department visits for evaluation and management
  • Initial hospital care and subsequent intensive care for neonatal patient
  • Ophthalmological services
  • Psychological or neuropsychological test administration with automated instrument
  • Self-measured blood pressure
  • Standardized cognitive performance testing

The updated Telemedicine medical policy (#91604) will be released on May 11, 2023. All billing and coding updates will be effective May 12, 2023. 

Place of service (POS) codes

In 2021, we reverted to requiring professional providers to bill POS codes 02 or 10 for virtual services, as this was the standard prior to the COVID-19 PHE. CMS and MDHHS recently released updated telehealth guidelines, and we’re making the following update to align all our plans to a new standard virtual care billing criteria.

Effective July 1, 2023, professional providers performing virtual services for any Priority Health member ¬should bill the POS code specific to the location where the member would have been seen in person, along with the appropriate modifier to indicate the virtual care method used:

  • 95: Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
  • 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System
  • GT: Via interactive audio and video telecommunication systems
  • GQ: Via asynchronous telecommunications system

Providers can begin billing as described above on May 12, 2023. We’ll also accept POS 02 and 10 through July 1, 2023.

Be sure to reference our Telemedicine medical policy (#91604) which outlines how our Commercial and Individual ACA plans adhere to the list of services defined for synchronous and asynchronous telehealth services.

We’ll follow the telehealth guidelines defined by CMS and MDHHS for Medicare and Medicaid respectively: