Univera Healthcare Updates on COVID-19 (Coronavirus)
Last Updated: 9/13/2022
COVID-19 Information and Resources
We are closely monitoring Novel Coronavirus (COVID-19). Our top priority is the health and well-being of the members that we serve. We are also committed to sharing the information we have when it becomes available to us. Because information is changing and evolving daily, please check back regularly. We are in contact with local, state and federal health and other officials and we will implement applicable orders, regulations,and requirements as they become effective.
Please continue to refer to the following websites for up-to-date health information:
§ U.S. Centers for Disease Control and Prevention
§ New York State Department of Health
§ Your County Health Department
We also encourage you to check our News and Updates regularly for communication updates. Type COVID-19 in the Search area. Keep in mind that you must be logged in with your username and password to access all news updates.
THANK YOU for your patience, understanding and collaboration as we all rally to navigate this new health care landscape.
For all products and lines of business (including individuals with coverage through a self-funded employer group), the Health Plan will provide coverage with no member cost-share for COVID-19 diagnostic/viral testing as well as antibody testing provided or referred by a health care provider. This includes the testing of asymptomatic individuals with no known or suspected exposure to the virus.
Testing for pandemic control or surveillance (e.g., testing required by the government, an employer, school, camp, etc.) is generally not covered by the Health Plan. Pursuant to guidance issued on December 13, 2021 by the New York State Department of Health, testing for surveillance or pandemic control is now covered in full only for Medicaid Managed Care (including the Health and Recovery Plan, or HARP) Child Health Plus and the Essential Plan.
COVID-19 testing conducted as part of pre-operative testing will be covered in full; all other preoperative tests are subject to cost-share, depending on the member’s benefit.
COVID-19 testing during an inpatient hospital stay prior to transfer to post-acute care (skilled nursing facility or long-term care) is considered part of the hospital DRG.
During the public health emergency, state and federal governments are issuing frequent COVID-19-related guidance. Our Health Plan’s policies and communications are subject to change accordingly.
Important Information for Pharmacies
Pharmacies providing medically appropriate COVID-19 testing for Commercial, Medicaid or Medicare members may submit claims using the National Council for Prescription Drug Programs COVID-19 testing billing methodology. For additional information, please refer to the following billing guidance documents:
For Medicaid members: NYS Medicaid COVID-19 Sample Collection and Testing Claims SubmissionOpen a PDF.
Please note that the over-the-counter tests covered for Medicaid members are also covered for Essential Plan and Child Health Plus members.
For Commercial members: Commercial COVID-19 Sample Collection and Testing Claims SubmissionOpen a PDF.
For Medicare members: Medicare Advantage COVID-19 Sample Collection and Testing Claims SubmissionOpen a PDF
For additional information, please visit the ESI Pharmacy Resource Center, or contact the ESI Pharmacy Technical Help Desk at 1-800-922-1557.
Administrative Policy AP-26: COVID-19 Viral and Antibody Testing & Supplies
The Health Plan has implemented Administrative Policy 26 - COVID-19 Viral and Antibody Testing & SuppliesOpen a PDF, to define the coverage, reimbursement and billing guidelines for COVID-19 viral and antibody testing. This policy applies to participating and non-participating practitioners, facilities, laboratories and pharmacies and all lines of business effective March 13, 2020, the date of the national state of emergency declaration.
Please refer to the Health Plan’s Administrative Policy, AP-26 Viral and Antibody Testing, (select the Administrative Policies card. User name and password required).
The links below contain COVID-19 coding release information issued by the American Medical Association, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services. These independent sources are not maintained by the Health Plan and are therefore subject to change.
- CPT Assistant January 2021, Special Edition, Vaccine CodingOpen a pdf
- CPT Assistant December 2020, Special Edition, Vaccine CodingOpen a pdf
- Appendix Q - COVID-19 Vaccine TableOpen a pdf
- CPT Assistant November 2020, Special EditionOpen a pdf
- CPT Assistant November 2020, Vaccine CodingOpen a pdf
- CPT Assistant October 2020, Special EditionOpen a pdf
- CPT Assistant September 2020 Update, Special EditionOpen a pdf
- CPT Assistant August 2020 Update, Special EditionOpen a pdf
- CPT Assistant June 2020 Update, Special EditionOpen a pdf
- CPT Assistant May 2020 Update, Special EditionOpen a pdf
- AMA CPT Lab Guidelines 4.1.2020Open a pdf
- AMA CPT Lab guidelines 3.13.2020Open a pdf
- CDC Update Effective January 1, 2021: New Codes for CoronavirusOpen a pdf
- CDC Release 10.1.20 through 9.30.2021: Guidelines for U07.1Open a pdf
- CMS ICD10 Coding Guidelines (updated January 1, 2021)Open a pdf
- CMS HCPCS Quarterly Update Open a pdf
The time frames below are subject to change, dependent on decisions made at the state and federal levels.
As we receive updates from New York state or the federal government, we will refresh this information. Please check back regularly.
- The Federal Public Health Emergency has been extended to 10/13/2022. This governs COVID-related telehealth services and testing/visits, out-of-network vaccine coverage, and the DRG reimbursement increase.
- The NYS Emergency Regulation on Testing/Visits has been extended to 12/7/2022. This governs the cost-share waiver for testing, diagnosis, and office/emergency room visits, and telehealth when the purpose is to diagnose COVID-19.
- The NYS Emergency Regulation on Telehealth, which governed COVID-19 and non-COVID-19-related telehealth services, expired on June 4, 2021. The Health Plan made a business decision to continue waiving member cost-share for in-network telehealth services for fully insured members* through 12/31/2021. For dates of service on or after 1/1/2022, please collect the appropriate member cost-share for in-network telehealth services provided to fully insured members*.
- The Health Plan made a business decision to continue waiving member cost-share for COVID-19 treatment (e.g., inpatients stays, monoclonal antibody treatment, etc.) for fully insured members* through 12/31/2021. For dates of service on or after 1/1/2022, please collect the appropriate member cost-share for COVID-19 treatment provided to our fully insured members*.
*Please note: Self-funded groups may have different cost-share waiver arrangements for telehealth services and COVID-19 treatment, so please check member coverage before each visit to determine member cost-share responsibility.
A telehealth visit is an option for initial screenings when an in-office visit is not an option. Telehealth services are covered under all product lines.
In-network telehealth visits will be covered with no member cost-share when the services would have been covered under the member’s policy if delivered in-person, including behavioral health treatment. To be covered as an office visit, the telehealth consultation must include all elements necessary for the service to be considered an office visit.
We also encourage you to visit our Telehealth Resources page.
Member Cost-Share for Telehealth Services
For Medicare Advantage members, we will cover COVID-19 related telehealth services with no member cost-share through the end of the federal public health emergency (refer to the Regulatory Time Frames tab for current expiration date). This date may be extended based on NYS and/or federal requirements.
COVID-19-Related Telehealth Services
Under federal guidance, COVID-19-related telehealth services will remain covered in full with no member cost-share through the end of the federal public health emergency (refer to the Regulatory Time Frames tab for current expiration date) for all lines of business.
Non-COVID-19-Related Telehealth Services
In accordance with the NYS emergency regulation, for members covered by commercial fully insured products and members enrolled in self-funded groups that have opted in to waive member cost-share, all telehealth services (COVID-19 and non-COVID-19) must be covered in full with no member cost-share through the expiration of the NYS emergency regulation (refer to the Regulatory Time Frames tab for current expiration date). For these members, we will re-institute the customer cost-share responsibility under the member’s benefit for non-COVID-19 telehealth services when the NYS emergency regulation expires.
Please note: Self-funded groups may have different cost-share waiver arrangements for telehealth services treatment, so please check member coverage before each visit to determine member cost-share responsibility.
We will continue to reimburse all telehealth services at the same rate as the corresponding face-to-face CPT/HCPCS code. This applies to all lines of business and may be extended for some or all programs based upon NYS and/or federal requirements. We provide advance written notice of any reimbursement updates for telehealth services.
We are closely monitoring the supply of medications that are available during the COVID-19 outbreak.
We have implemented early refill overrides for prescription medications. Pharmacists can make the override at the point of sale.
We are increasing access to prescription medications by waiving early medication refill limits on 30-day prescription maintenance medications (consistent with a member’s benefit plan).
Members are also encouraged to use their 90-day mail order benefit for prescription medications.
We will ensure formulary flexibility if shortages or access issues do occur. Emergency prescription drug overrides are also available as part of our standard exception process on an individual member basis.
On August 5, 2020, the New York State Department of Financial Services (“DFS”) issued Circular Letter No. 14 (2020) regarding charges for personal protective equipment (“PPE”) by health care and dental care providers. The Circular Letter addresses complaints received from some individuals who have been charged for PPE used by their health care/dental care provider and reminds providers that they are limited to collecting applicable patient health plan cost-sharing and prohibited from balance billing.
The Circular Letter also advises health care and dental care providers that they must refund health plan members for any fees collected for PPE. To review the Circular Letter, please visit the DFS website.
The Health Plan has not changed its reimbursement policy related to PPE, supplies or materials; they are not covered and are considered inclusive to the service provided.
The Centers for Medicare & Medicaid Services has issued guidance that effective January 1, 2022, Medicare Advantage (MA) plans will be responsible for the cost of both the vaccine product and administration fee for COVID-19 vaccines provided to MA members. This also includes approved COVID-19 booster doses.
Medicare Billing for COVID-19 Vaccine Shot Administration | CMS
For dates of service on or after January 1, 2022, please bill Univera Healthcare (not Original Medicare) for the COVID-19 vaccine product and administration fee provided to MA members if the product was not received free of charge from the federal government.
We are awaiting word from the NYS Department of Health related to COVID-19 vaccine billing for members with coverage under a Safety Net product. We will share the details as we receive them.
Provisions of the CARES Act require COVID-19 vaccines be administered with no member-cost share (covered in full) regardless of an individual’s health insurance benefits or coverage.
Please continue to refer to the Center for Medicare & Medicaid Services website for important information related to provider vaccine reporting requirements and other key resources. The New York State Department of Health website also provides information related to ordering, receiving and administering the vaccine.
We also encourage you to review the state’s vaccination training information, which includes details about the expanded eligible pool of trainees who can administer vaccinations at a point-of-dispensing site, or "POD site" (flexible vaccination sites that can be set up in any community) provided they have received the required training. Please note that students and medical professionals in training must submit claims for vaccine administration under the supervising physician.
Educational Resource for Patients
Please feel free to download and print our informational flier, Stay Safe. Get a COVID-19 Vaccine, available in EnglishOpen a PDF and SpanishOpen a PDF to share with your patients. You can also request copies from your Provider Relations representative.
Vaccine Counseling Billing Information
The unlisted CPT code 99429 may be used to bill for COVID-19 vaccine counseling provided to unvaccinated individuals who do not receive a COVID-19 vaccine.
For members with coverage under Medicaid Managed Care, including the Health and Recovery Plan (HARP), and Child Health Plus (CHP), vaccine counseling is covered in full for dates of service on or after December 1, 2021.
All other lines of business are subject to the applicable member benefit and cost-share responsibility.
Provider Billing, Reimbursement and Cost-Share Information
The initial supply of COVID-19 vaccines will be provided free of charge by the federal government; Univera Healthcare will provide reimbursement for the administration of the vaccine only. This may change when the public health emergency is lifted; we will communicate any changes as they become available from the federal government.
Provisions of the CARES Act require COVID-19 vaccines to be administered with no member-cost share (covered in full) regardless of an individual’s health insurance benefits or coverage.
For the Safety Net line of business/products (MyHealthSM, MyHealth PlusSM, Child Health Plus, Healthy NY, and the Essential Plan), Univera Healthcare will mirror New York State Medicaid rates for vaccine administration.
If NYS Medicaid has not issued a rate for a covered service, Univera Healthcare will use the reimbursement rate used by CMS until a rate is issued by NYS DOH. If NYS DOH subsequently issues a lower rate or determines that a service is not covered or is separately reimbursable, we will auto-adjust any impacted claims.
For all other products and lines of business, Univera Healthcare will mirror the Medicare geographically adjusted reimbursement rates established by CMS.
Pharmacy Claims Billing Information
Pharmacies providing COVID-19 vaccinations approved under the FDA Emergency Use Authorization and Advisory Committee on Immunization Practices (ACIP) for Commercial, Medicaid, and Medicare members may submit claims using the National Council for Prescription Drug Programs COVID-19 vaccine billing methodology. For additional information, please refer to the pharmacy billing guidanceOpen a PDF.
Pre-exposure prophylactic therapy for those not infected with a COVID-19 viral variant:
The U.S. Food and Drug Administration (FDA) authorized the following investigational monoclonal antibody combination product under emergency use authorization (EUA) for pre-exposure prophylaxis of COVID-19. This combination product is for use in adults and pediatric patients 12 years of age and older weighing at least 40 kg who may be unable to receive a COVID-19 vaccine due to severe allergic reaction or inability to support an adequate immune response.
- Tixagevimab co-packaged with cilgavimab, administered as two separate consecutive intramuscular injections
We encourage you to review the FDA fact sheet for additional details, including authorized use, limitations, administration guidelines, contraindications and more.
Post-exposure treatment therapy for individuals infected with a COVID-19 viral variant:
The FDA issued an EUA for the following investigational monoclonal antibody therapies and oral antiviral agents for the treatment of a mild-to-moderate COVID-19 viral variant in adult and pediatric patients.
We encourage you to review the FDA fact sheets on these drugs for additional details, including authorized use, limitations, administration guidelines, contraindications and more.
Post-exposure treatment therapy options
Monoclonal antibody therapies
- Sotrovimab (Important: The FDA revised the EUA for sotrovimab as of March 25, 2022; when non-susceptible variants are prevalent (as they currently are in New York state), the use of sotrovimab is no longer authorized. Learn more.)
- Remdesivir (Veklury) (this treatment is not provided free of charged by the federal government)
- Casirivimab/imdevimab (Important: The FDA revised the EUA for casirivimab/imdevimab as of January 24, 2022; when non-susceptible variants are prevalent, the use of casirivimab/imdevimab is no longer authorized.)
- Bamlanivimab/etesevimab (Important: The FDA revised the EUA for bamlanivimab/etesevimab as of January 24, 2022; when non-susceptible variants are prevalent, the use of bamlanivimab/etesevimab is no longer authorized.)
- Bamlanivimab (Important: The FDA revoked emergency use authorization for bamlanivimab as of April 16, 2021, when administered on its own (codes Q0239, M0239). Therefore, the Health Plan will not cover the administration of this treatment for any line of business.)
Billing, Cost-Share and Reimbursement Information
The Health Plan will provide reimbursement for infusion of the antibody treatments when the monoclonal antibody product is received free of charge from the federal government. The Health Plan will also provide reimbursement for monoclonal antibody products that are not being provided free of charge from the federal government as noted below:
- For the Medicare Advantage line of business/products, the Centers for Medicare & Medicaid Services (CMS) announced that beginning November 10, 2020, Medicare beneficiaries can receive coverage of monoclonal antibodies to treat mild-to-moderate COVID-19 with no cost-sharing during the federal public health emergency. Claims for infusion services should be billed to the Health Plan for dates of service on or after January 1, 2022. For more information, visit Monoclonal Antibody COVID-19 Infusion |CMS.
- For Univera Healthcare MyHealthSM, MyHealthSM Plus, and Health NY, Univera Healthcare will mirror New York State Medicaid rates for monoclonal antibody administration. When NYS Medicaid does not have an established rate, Univera Healthcare will use the geographically adjusted reimbursement rate established by CMS. Medicaid out-of-network providers must be participating with fee-for-service, even if not participating with Univera Healthcare, to be reimbursed for these antibody treatments.
- Child Health Plus and Essential Plan will follow standard coverage/benefit guidelines and reimbursement methodology for this treatment.
- For all other products and lines of business, the Health Plan will mirror the geographically adjusted Medicare reimbursement rates established by CMS.
- For dates of service on or after January 1, 2022, please collect the appropriate member cost-share for COVID-19 treatment provided to our fully insured members. Self-funded groups may have different cost-share waiver arrangements for COVID-19 treatment, so please check member benefits to determine member cost-share responsibility.
Oral antiviral agents
- Nirmatrelvir co-packaged with ritonavir (Paxlovid) (this treatment is provided free of charge by the federal government)
- Molnupiravir (this treatment is provided free of charge by the federal government)
Pharmacy Quantity Limits and Cost-Share Information
- Oral treatments may require a member cost-share not exceeding $12 for the pharmacy dispensing fee (Note: There is no cost-share responsibility for members with Medicare or Medicaid coverage)
- Quantities are limited as below:
- Molnupiravir – Quantity limit of 40 capsules per 180 days
- Nirmatrelvir/ritonavir (Paxlovid) – Quantity limit of 30 tablets per 180 days