Excellus BCBS Updates on COVID-19 (Coronavirus)

Last Updated: 4/9/2021

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, the Health Plan will provide coverage with no member cost-share for COVID-19 diagnostic/viral testing as well as antibody testing. The testing must be medically appropriate for the diagnosis and treatment of an individual by an attending provider as evidenced by an order from the attending provider.  

Testing that is ordered or performed solely for purposes of pandemic control or re-opening the economy, and not based on a determination by an attending provider that the test is medically appropriate for the diagnosis and treatment of an individual member, is not covered.  This includes tests performed on an asymptomatic individual solely to assess health status as required by parties such as an employer, common carrier, school, camp, travel authority/advisory, nursing home (to visit a resident), government/public health agency or research/epidemiologic study, or when ordered upon the request of a member solely to facilitate the member’s desire to self-assess COVID-19 immune status.

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.

Antibody Tests

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 Testing

  • 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.

Additional Information 

Reminders

  • Viral testing to rule out an active COVID-19 infection in patients prior to elective procedures is considered a component of pre-admission testing and is not reimbursed separately.  
  • Viral 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.

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 4/21/2021. 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 has been extended to 5/4/2021. This extends specifically to COVID-19 and non-COVID-19-related telehealth services.

  • The NYS Emergency Regulation on Testing/Visits has been extended to 5/4/2021. 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 has been extended to 4/26/2021. This waives member cost-share for in-network outpatient mental health services provided to essential workers.

  • The NY State of Emergency (NYSOE) is separate and distinct from the NYS emergency regulations listed above. The NYSOE is set to expire 5/6/2021, and the Health Plan is following the NYSOE and all date extensions for the cost-share waiver for COVID-19 treatment.

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 public health emergency, currently set to expire April 21, 2021. 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 (which is currently set to expire April 21, 2021) 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 (which is currently set to expire on March 5, 2021; date subject to change). 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. 

It’s important to note that some of our self-funded groups have opted out of waiving member cost-share for non-COVID-related telehealth services. Please review the listOpen a PDF before providing non-COVID-related telehealth services to our members. (secure login required to access list)

Reimbursement

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.)

To ensure that you are ready to order, receive and administer the COVID-19 vaccine, please refer to the Center for Medicare & Medicaid Services website. This site provides important information related to provider vaccine reporting requirements and other resources that will be critical to your practice or facility as you prepare to vaccinate against COVID-19. The New York State Department of Health website also provides information critical 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

Our Important Information About the COVID-19 Vaccine educational piece, available in EnglishOpen a PDF and SpanishOpen a PDF,  provides answers to frequently asked questions and shares CDC guidance about what to expect after receiving the vaccine. Please feel free to download and print copies for your office. You can also contact your Provider Relations representative to request copies.

Provider Billing, Reimbursement and Cost-Share Information

The initial supply of COVID-19 vaccines will be provided free of charge by the federal government; Excellus BCBS 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 (HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, Premier Option Plus, Child Health Plus and Premier Child Health Plus, Healthy NY and the Essential Plan) Excellus BCBS will mirror New York State Medicaid rates for vaccine administration.

If NYS Medicaid has not issued a rate for a covered service, Excellus BCBS 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, Excellus BCBS 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.  

Billing, Cost-Share and Reimbursement Information

The initial supply of COVID-19 monoclonal antibodies will be provided free of charge by the federal government. 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 HMOBlue Option, Blue Choice Option, Premier Option, Blue Option Plus, Premier Option Plus, and Healthy NY, Excellus BCBS will mirror New York State Medicaid rates for monoclonal antibody administration. When NYS Medicaid does not have an established rate, Excellus BCBS 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 Excellus BCBS, 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, Excellus BCBS 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.