Medicare Member Plan Benefits for Applicable COVID-19 Testing, Screening, and Treatment Services
8/15/2023
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Posted by Provider Relations
Earlier this year, the Biden Administration announced that the federal Public Health Emergency (PHE) related to the COVID-19 pandemic ended on May 11, 2023.
During the PHE, we followed guidance from the Centers for Medicaid & Medicare Services (CMS) and instituted temporary waivers for select services. This action ensured that critical care could be quickly delivered to our members during a time of heightened need. Beginning May 12, 2023, these temporary waivers expired, and our members’ Medicare plan benefits are reinstated for the following services:
| Service | Member Liability | Prior Auth Needed? |
| COVID-19 Testing and Screening (Administered by Provider) | Per member plan benefits | No |
| COVID-19 Vaccinations | $0 member cost-share for vaccine administration* | No |
| COVID-19 Monoclonal Antibody Treatments | $0 member cost-share for treatment administration* | Prior authorization only required for CPT code Q0221 |
*Vaccine ingredient cost is still covered directly by Medicare FFS.
Alongside these waivers, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. This increase applied to claims that included the applicable COVID-19 ICD-10-CM diagnosis code and met the date of service requirement. When the PHE ended on May 11, 2023, these add-on payments are no longer included for discharge dates of service as of May 12, 2023 and thereafter.
Fidelis Care is committed to providing a smooth transition for both our members and providers as we resume business as usual. While we will continue to communicate any updates to our business practices directly to our provider partners, we always highly recommend that providers verify member eligibility, benefits, and prior authorization requirements before rendering services.