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Updated CMS Guidelines for COVID-19 Tests and Booster Shot

Updated CMS Guidelines for COVID-19 Tests and Booster Shot

Billing and coding guidelines for various medical specialities are constantly getting updated due different COVID-19 variants. Before delivering services, providers are really not sure about insurance coverage for that specific procedure. As Public Health Emergency (PHE) has extended beyond 16th April 2022 by 90 days, various waivers are continued, making no change in billing guidelines in pandemic. In fact, concerned authority extended the current COVID-19 pandemic telehealth waivers for five months beyond the end of the public health emergency. In month of April 2022, CMS also announced couple of important billing update for COVID-19 tests and booster dose. We shared billing update for free COVID-19 tests and second free booster dose in detail in this article.

Medicare to Cover Over-the-Counter COVID-19 Tests

On 4th April 2022, CMS announced that more than 59 million Americans with Medicare Part B, including those enrolled in a Medicare Advantage plan, now have access to Food and Drug Administration (FDA) approved, authorized, or cleared over-the-counter COVID-19 tests at no cost. People with Medicare can get up to eight tests per calendar month from participating pharmacies and health care providers for the duration of the COVID-19 public health emergency. If beneficiary is in a Medicare Advantage plan, the tests covered under this initiative will be covered outside of existing plan’s coverage, and in addition to any over-the-counter tests that may be covered under the plan as a supplemental benefit. Medicare won’t cover over-the-counter COVID-19 tests for Medicare Part A (Hospital Insurance) coverage, but beneficiary may be able to get free tests through other programs.

This is the first time that Medicare has covered an over-the-counter self-administered test at no cost to beneficiaries. This new initiative enables payment from Medicare directly to participating eligible pharmacies and other health care providers to allow Medicare beneficiaries to receive tests at no cost, in addition to the two sets of four free at-home COVID-19 tests. National pharmacy chains are participating in this initiative, including: Albertsons Companies, Inc., Costco Pharmacy, CVS, Food Lion, Giant Food, The Giant Company, Hannaford Pharmacies, H-E-B Pharmacy, Hy-Vee Pharmacy, Kroger Family of Pharmacies, Rite Aid Corp., Shop & Stop, Walgreens and Walmart.

Providers and suppliers eligible to participate include certain types of pharmacies and other health care providers who are enrolled in Medicare and able to furnish ambulatory health care services such as preventive vaccines, COVID-19 testing and regular medical visits. To ensure that people with Medicare have access to these tests, Medicare is not requiring participating eligible pharmacies and health care providers go through any new Medicare enrollment processes. If a health care provider currently provides ambulatory health care services such as vaccines, lab tests or other clinic type visits to people with Medicare, then they are eligible to participate in this initiative.

Second COVID-19 Booster Shot at No Cost

On 4th April 2022, the Centers for Medicare & Medicaid Services (CMS) announced it will pay for a second COVID-19 booster shot of either the Pfizer-BioNTech or Moderna COVID-19 vaccines without cost sharing as it continues to provide coverage for this critical protection from the virus. People with Medicare pay nothing to receive a COVID-19 vaccine and there is no applicable co-payment, coinsurance or deductible. People with Medicaid coverage can also get COVID-19 vaccines, including boosters, at no cost.

The Centers for Disease Control and Prevention (CDC) recently updated its recommendations regarding COVID-19 vaccinations. Certain immunocompromised individuals and people ages 50 years and older who received an initial booster dose at least four months ago are eligible for another booster to increase their protection against severe disease from COVID-19. Additionally, the CDC recommends that adults who received a primary vaccine and booster dose of Johnson & Johnson’s Janssen COVID-19 vaccine at least four months ago can receive a second booster dose of a Pfizer-BioNTech or Moderna COVID-19 vaccine.

We shared updated CMS guidelines for COVID-19 tests and booster shot for reference purpose only, you can visit below mentioned CMS links for more detailed understanding. Medisys Data Solutions is a leading medical billing company providing billing and coding services for various medical billing specialities. If you need any assistance in medical billing for your practice, contact us at 302-261-9187

Reference: Medicare Covers Over-the-Counter COVID-19 Tests

Eligible Individuals Can Receive Second COVID-19 Booster Shot at No Cost

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