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Important Updates Regarding Coronavirus COVID-19

• Posted by Provider Relations -  October 3, 2025


Fidelis Care would like to inform provider of COVID-19 vaccine recommendations issued by the NYS Commissioner of Health, the New York City (NYC) Department of Health and Mental Hygiene and the Northeast Public Health Collaborative . Coverage policies of COVID-19 vaccines and guidance for administration of those vaccines follow the recommendations of healthcare professional organizations and are consistent with the scientific evidence supporting their safety and efficacy. Updated recommendations are included below.

 COVID-19 Vaccination Recommendations for Adults

Vaccination against COVID-19 is recommended for all adults (>18 years).

·         All adults 65 years and older should be vaccinated

·         Adults 19-64 years with risk factors for severe COVID-19 disease (e.g., chronic conditions, immunocompromised status) should be vaccinated (For a list of conditions please see Table 1 in the Health Advisory: 2025-2026 COVID-19 Immunization Guidance for Adults , found here:  2025–2026 COVID-19 Immunization Guidance for Adults

·         Adults 19-64 years at higher risk of exposure (e.g., healthcare workers, congregate care settings) should be vaccinated

·         Adults 19-64 who are household contacts of persons at high risk of severe disease should be vaccinated

·         For adults without underlying conditions, vaccination remains recommended as it reduces the risk of symptomatic infection, severe illness, and death.


COVID-19 Vaccination Recommendations for Children and Adolescents

COVID-19 vaccination recommendations for children and adolescents (defined as ages 6 months to 18 years) are as follows:

·         All children ages 6-23 months should be vaccinated.

·         Children and adolescents ages 2-18 years who fall within one of the following subgroups should be vaccinated:

o    At high risk for severe COVID-19 (For recommended high risk populations, please see Table 1, Appendix A in the Health Advisory: 2025-2026 COVID-19 Immunization Guidance for Children , found here: 2025–2026 COVID-19 Immunization Guidance for Children

o    Living in a long-term care facility or other congregate setting

o    Have never been vaccinated against COVID-19

o    Whose household members are at high risk for severe COVID-19

·         Vaccination may also be provided to children ages 2-18 years who do not fall into one of the above categories, at the request of their parent/guardian.

 

As a reminder, providers who provide care to children between the ages of 0 and 18 years will be reimbursed for the cost of the vaccine and the administration fee when medically necessary pediatric vaccines are not included in the Vaccines For Children program.


COVID-19 Vaccination Recommendations for Pregnant People

All pregnant people should be vaccinated against COVID-19.

·         Vaccination may occur in any trimester.

·         All individuals in the postpartum period should be vaccinated against COVID-19.

·         All lactating individuals should be vaccinated against COVID-19. There is no need to stop or delay breastfeeding.

·         All individuals contemplating pregnancy or actively trying to conceive should be vaccinated against COVID-19. There is no need to delay pregnancy following a COVID-19 vaccine.

 

Additional information on COVID-19 vaccination recommendations can be found at https://coronavirus.health.ny.gov/covid-19-guidance-repository.

COVID-19 Coverage as of October 1, 2024

 

 

Medicaid/CHP/HARP

Essential Plan

Marketplace

Medicare

 

Immunizations

Covered with no cost-sharing when provided by a participating provider.

 

 

Not covered out of network.

Covered with no cost-sharing when provided by a participating provider.

 

 

Not covered out of network.

Covered with no cost-sharing when provided by a participating provider.

 

 

Not covered out of network.

Covered with no cost-sharing when provided by a participating or a non-participating provider.

 

 

Prior Authorization not required.

 

In-Office Testing

 

Covered with no cost-sharing when provided by a participating provider.

 

 

Not covered out of network.

Covered with cost-sharing effective 10/1/24, when provided by a participating provider.

 

 

Not covered out of network.

Covered with cost-sharing when provided by a participating provider.

 

 

Not covered out of network.

Covered with cost-sharing when provided by a participating or a non-participating provider.

 

 

Prior Authorization not required.

Specimen collection and high throughput testing is not covered. For Medicaid enrollees, there is FFS reimbursement effective 5/12/23, for PCR, antigen, multiplex, and antibody tests For Marketplace enrollees, office visit cost-sharing has been reinstated. All other testing codes will be covered until 9/30/24 across all LOBs.

 

Over-the Counter Tests

Medicaid/HARP - Not covered.

CHP - Up to 2 OTC tests every 30 days.

Up to 8 OTC tests per month covered with cost-sharing.

Not covered.

Covered through Medicare FFS (fee for service).

 

COVID-19 Treatment

Covered with no cost-sharing when provided by a participating.

 

Out of network coverage requires prior authorization.

Covered with cost-sharing effective 10/1/24, when provided by a participating.

 

Not covered out of network, unless in an Emergency Department in a hospital setting.

Covered with cost-sharing when provided by a participating provider.

 


Not covered out of network.

Covered with cost-sharing when provided by a participating provider.

  


Out of network coverage dependent on plan.

 

Telemedicine

Telemedicine is covered with no cost-sharing when provided by a participating provider.

 

 

 

 

Not covered out of network.

Covered with cost-sharing effective 10/1/24, when provided by a participating provider.

 

 

 

  

Not covered out of network.

Telemedicine rendered via Fidelis Care’s Telemedicine Program is covered with no cost-sharing.   Telemedicine by other participating providers is covered with cost-sharing.

 

 

Not covered out of network.

Telemedicine* is covered with no cost-sharing when provided by a participating provider.

 

Not covered out of network.

 

* As of 5/12/2023, Medicare will no longer cover codes “99441” through “99443” for telemedicine.

 

 

Vaccine Counseling : Effective 5/12/2023, Medicaid, Essential Plan, and Marketplace members under the age of 21 are covered as a standalone service, while members 21 years old and older are not separately reimbursable and should be included in the E&M.

Coding – Updated May 1, 2025

Fidelis Care has updated our claims systems to reflect the codes currently reimbursable across all lines of business.
Coding - Updated May 1, 2025

Code Type

Code

Effective

Testing (PCR)

U0001

02/04/2020

Testing (PCR)

U0002

5/12/2023

Testing (PCR)

87635

5/12/2023

Testing (Infectious Disease)

0202U

5/20/2020

Testing (Infectious Disease)

0225U

8/10/2020

Testing (Infectious Disease)

0240U

10/6/2020

Testing (Infectious Disease)

0241U

10/6/2020

Testing (Antigen)

87426

5/12/2023

Testing (Antigen)

87811

5/12/2023

Testing (Antigen)

0223U

6/25/2020

Testing (Antigen)

0224U

6/25/2020

Testing (sVNT)

0226U

8/10/2020

Testing

86413

9/8/2020

Testing (Multiplex)

87428

5/12/2023

Testing (Multiplex)

87636

5/12/2023

Testing (Multiplex)

87637

5/12/2023

Testing (Antibody)

86328

5/12/2023

Testing (Antibody)

86769

5/12/2023

Mutation identification SARS CoV-2

87913

2/21/2022

Screening (Neutralizing Antibody)

86408

8/10/2020

Screening (Neutralizing Antibody)

86409

8/10/2020

Injection, Remdesivir, 1MG

J0248

10/1/2024

Genentech Monoclonal - Tocili Injection

Q0249

6/24/2021

Genentech Monoclonal - Tocili 1st Infusion

M0249

6/24/2021

Genentech Monoclonal - Tocili 2nd Infusion

M0250

6/24/2021

Covid-19 Convalescent Plasma Infusion

C9507

12/28/2021

NEW – Novavax Covid-19 Vaccine, Adjuvanted, Ages 18 years and older

91304

7/13/2022

Immunization administration by intramuscular (IM) injection of SARS-CoV-2 (COVID-19) vaccine, single dose

90480

09/11/2023

Pfizer-BioNTech SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, tris-sucrose, 3 mcg/0.3 mL dose

91318

09/11/2023

Pfizer-BioNTech SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, tris-sucrose, 10 mcg/0.3 mL dose

91319

09/11/2023

Pfizer-BioNTech SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, tris-sucrose, 30 mcg/0.3 mL dose

91320

09/11/2023

Moderna SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 25 mcg/0.25 mL dose

91321

09/11/2023

Moderna SARS-COV-2 (COVID-19) vaccine, mRNA, spike protein, LNP, preservative free, 50 mcg/0.5 mL dose

91322

09/11/2023