Univera Healthcare Updates on COVID-19 (Coronavirus)
Last Updated: 8/26/2021
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, but excludes testing conducted for surveillance or pandemic control (e.g., testing required by the government, an employer, school, camp, etc.), which is not covered by the Health Plan.
COVID-19 testing conducted as part of a lab panel for pre-operative reasons or otherwise will be covered in full, with all other tests within the panel 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.
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 review the policy by clicking on the link above (username and password required).
Antibody and Antigen Testing
The following information regarding antibody testing and antigen testing should be considered when determining the appropriateness of these tests. We also encourage you to review these testing guidelinesOpen a PDF.
According to the Centers for Disease Control and Prevention (CDC):
- Viral (nucleic acid or antigen) testing to diagnose acute infection is recommended.
- Antibody testing to diagnose acute infection, as the sole basis for diagnosis, or to rule out COVID-19, is not recommended. The antibody response in affected patients remains largely unknown and the clinical values of antibody testing have not been fully demonstrated.
CDC Interim Guidance for COVID-19 Antibody Testing
On August 1, 2020, the CDC issued interim guidelines for COVID-19 antibody testing, which include the following:
- Serologic testing should not be used to determine immune status in individuals until the presence, durability, and duration of immunity is established.
- Serologic test results should not be used to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities or used to make decisions about returning persons to the workplace.
- Additional data are needed before modifying public health recommendations based on serologic test results, including decisions on discontinuing physical distancing and using personal protective equipment.
Recommendations for Use of Serologic/Antibody Testing
- The U.S. Food and Drug Administration (FDA) now requires commercially marketed serologic tests to receive Emergency Use Authorization.
- Serologic assays may be used to support clinical assessment of persons who present late in their illnesses when used in conjunction with viral detection tests.
- Serologic assays may be used if a person is suspected to have a post-infectious syndrome caused by SARS-CoV-2 infection (e.g., multisystem inflammatory syndrome in children, or MIS-C).
Limitations of Current Antibody Testing
- Some tests may exhibit cross-reactivity with other coronaviruses, such as those that cause the common cold. This could result in false-positive test results.
- Definitive data are lacking, and it remains uncertain whether individuals with antibodies (neutralizing or total) are protected against reinfection with SARS-CoV-2, and if so, what concentration of antibodies is needed to confer protection.
- Antigen tests can be used in a variety of testing strategies to respond to the coronavirus disease 2019 (COVID-19) pandemic. The purpose of this interim technical guidance is to support effective clinical use of antigen tests for different testing situations. This guidance applies to all clinical uses of antigen tests and is not specific to any particular age group or setting. Please review the CDC Interim Guidance for Antigen Testing.
- American Medical Association’s Serological Testing for SARS-CoV-2 Antibodies
- Association of Public Health Laboratories and Council of State and Territorial Epidemiologists, Public Health Considerations: Serologic Testing for COVID-19, Version 1 – May 7, 2020
- CDC Interim Guidelines for COVID-19 Antibody Testing
- Emergency Use Authorizations for Medical Devices. Coronavirus Disease 2019 (Covid-19)
- Important Information on the Use of Serological (Antibody) Tests for COVID-19 - Letter to Health Care Providers
- Infectious Diseases Society of America’s IDSA COVID19 Antibody Testing Primer
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 SARS-CoV-2 Vaccine CPT Codes 7.31.2021Open 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 10/18/2021. This governs COVID-related telehealth services and testing/visits, out-of-network vaccine coverage, and the DRG reimbursement increase.
- 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.
- The NYS Emergency Regulation on Testing/Visits has been extended to 10/1/2021. 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 Outpatient Mental Health for Essential Workers expired on 5/26/2021 and was not extended. This regulation waived member cost-share for in-network outpatient behavioral health services provided to essential workers. For dates of service on and after 5/27/2021, please collect the appropriate member cost-share for in-person outpatient behavioral health services.
- The NY State of Emergency (NYSOE) expired on June 24, 2021. The Health Plan made a business decision to continue waiving member cost-share for COVID-19 treatment for fully insured members* through at least 9/30/2021.
*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.
Please refer to our telehealth coding guidance gridOpen a PDF for assistance with the appropriate modifier and place of service code to use for the service rendered. This grid will be updated as needed, so please check back regularly.
We also encourage you to visit our Telehealth Resources page.
Member Cost-Share for Telehealth Services
For Medicare Advantage members, we will continue to cover both COVID-19 and non-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.
Some of our self-funded groups have opted out of waiving member-cost share for non-COVID-19 services provided via telehealth. The list of those groups who have opted out was included in our communication to you dated August 17, 2020. You should apply member cost-share (i.e., copay, coinsurance, deductible) for non-COVID-19 related telehealth services provided to our members who have coverage through the employer groups who have opted out of coverage in full for non-COVID-19 services.
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.
If you weren’t able to attend on January 28, 2021, you can now view our COVID-19 Vaccine Talk WebEx presentation with guest speaker Stephen Thomas, M.D., Chief of the Infectious Disease Division at SUNY Upstate Medical and lead principal investigator for the Pfizer vaccine trials. (When you open the link above, scroll down past the messaging and click the "Play" arrow to start the presentation.)
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 poster, COVID-19 Vaccine Information: 3 Things to Keep in Mind, available in EnglishOpen a PDF and SpanishOpen a PDF to display in your office. You can also request copies of a larger version of this poster from your Provider Relations representative.
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.
PLEASE NOTE: Claims for COVID-19 vaccines administered to Medicare Advantage members by Medicare Advantage contracted providers should be submitted to Original Medicare following the instructions included on the CMS website.
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 and Medicaid members may submit claims using the National Council for Prescription Drug Programs COVID-19 vaccine billing methodology. COVID-19 vaccine claims for Medicare members must be billed to the CMS Medicare Administrative Contractor (MAC), which is the beneficiary’s original Medicare Fee-for-Service program. For additional information, please refer to the pharmacy billing guidance.
The U.S. Food and Drug Administration issued an emergency use authorization for the following investigational monoclonal antibody therapies for the treatment of mild-to-moderate coronavirus disease 2019 (COVID-19) 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.
- tocilizumab (this treatment is not provided free of charge by the federal government)
- sotrovimab (this treatment is not provided free of charge by the federal government)
- 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 initial supply of COVID-19 monoclonal antibodies will be provided free of charge by the federal government, except as noted above. The Health Plan will provide reimbursement for infusion of the antibody treatments only. Please do not bill for the monoclonal antibody products you receive for free.
- 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 directly to Medicare fee-for-service through December 31, 2021. Medicare fee-for-service will reimburse providers directly during this time frame.
- 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, Univera Healthcare will mirror the geographically adjusted Medicare reimbursement rates established by CMS and will waive cost-share both in-network and out-of-network in accordance with our existing decision to waive cost-share for COVID-19 treatment services through the expiration of the New York State of Emergency. This decision also applies to those self-funded, Article 47, and Minimum Premium groups that have opted in.