New York State Medicaid Update - March 2020 Special Edition - COVID-19

New York State Medicaid Coverage and Reimbursement Policy for Services Related to Coronavirus Disease 2019 (COVID-19)

This guidance is outdated. Please refer to the September 2024 Updates to New York State Medicaid Coverage of Coronavirus Disease 2019 Services Special Edition issue of the Medicaid Update, for current COVID-19 billing and coverage guidance.

(This article was updated on March 27, 2020)

The New York State Department of Health (NYSDOH) is coordinating with federal and local partners to respond to COVID-19 as information becomes available. Reported illnesses have ranged from mild respiratory symptoms, similar to a cold, to severe illness, resulting in pneumonia and even death. Providers should have an emergency preparedness plan in place for their facilities. The latest NYS-specific information can be found on the NYSDOH website.

This guidance is effective immediately and shall remain in effect for the remainder of the disaster emergency declared by Executive Order No. 202, or until the issuance of subsequent guidance by the NYSDOH prior to the expiration of such state disaster emergency declaration.

The latest Centers for Disease Control and Prevention (CDC) guidance for healthcare professionals is available at the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html.

Treatment

Currently there is no available antiviral to treat COVID-19, though some international clinical trials are underway.

Vaccine

At this point there is not a vaccine for COVID-19. If a vaccine is developed, this guidance document will be updated.

Testing of Persons Under Investigation (PUI)

Currently COVID-19 tests are being conducted at the CDC, the NYS Wadsworth Center, and the New York City Public Health Laboratory. Tests performed for suspected individuals at these current public health sites are provided at no cost. Additionally, some hospitals and commercial laboratories are now authorized to perform COVID-19 testing.

When a test is ordered and referred to a public health lab, it is critical that the order form included with the test sample is legible and completed in its entirety.

Coverage and Copays

Some commercial laboratories have been granted approval to test for COVID-19. To ensure that cost-sharing is not a barrier to testing, NYS Medicaid will cover services including testing for COVID-19 and for physician, clinic, and emergency visits without copays for members when the purpose of the visit is testing, evaluation and/or treatment for COVID-19. Providers should follow CDC coding guidelines below when submitting claims to Medicaid.

Coding

NYS Medicaid will add Healthcare Common Procedure Coding System (HCPCS) codes as they become available. In February 2020, CMS developed the first HCPCS code ("U0001") to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for COVID-19. The second HCPCS billing code (>"U0002") allows laboratories to bill for non-CDC laboratory tests for COVID-19. There is now a third code for billing tests for COVID-19, "87635", released by the American Medical Association (AMA) on March 13,2020. This code has been adopted by some commercial laboratories enrolled in NYS Medicaid. Laboratories should follow CMS guidance and choose the appropriate code ("U0002" or "87635") for the test they perform. Only one code should be billed per patient, per test performed.

For additional information please see the laboratory fee schedule located at the following link: https://www.emedny.org/ProviderManuals/Laboratory/index.aspx.

Providers should follow CDC ICD-10-CM Official Coding Guidelines when selecting a diagnosis code to ensure proper reporting. To capture the reporting of COVID-19 in claims and surveillance data, CDC has designated a new diagnosis code to identify patients diagnosed with COVID19, "U07.1". The effective date for the new diagnosis code is April 1, 2020.

Claims submitted for COVID-19 tests and practitioner office visits for the purpose of COVID-19 testing, evaluation, and/or treatment should be identified as an emergency by reporting as Emergency Indicator = "Y". Institutional providers (emergency department, hospital outpatient/diagnostic and treatment center, FQHC, and hospital inpatient) should report Type of Admission Code = "1" to indicate an emergency when the purpose of the visit is for testing, evaluation, and/or treatment related to COVID-19.

Pharmacy

Medicaid covers a 90-day supply for most prescription and over-the-counter (OTC) maintenance medications. Practitioners and pharmacists should consider 90-day supplies of long-term maintenance medications for individuals in quarantine. Medicaid Managed Care questions regarding policy and billing guidance for 90-day supplies should be directed to the enrollee's Medicaid Managed Care plan. For up-to-date guidance on Pharmacy policy during the disaster emergency, please see the following link: https://www.health.ny.gov/health_care/medicaid/covid19/index.htm

Telehealth

NYS Medicaid expanded coverage of telehealth services in 2019. Per Insurance Law and Public Health Law, services that are covered under a comprehensive health insurance policy or contract cannot be excluded when the service is delivered via telehealth. During the disaster emergency, NYS Medicaid has updated its telehealth guidance, including expanding telehealth services to include telephonic services. For up-to-date guidance on the Telehealth policy during the disaster emergency, please see the following link: https://www.health.ny.gov/health_care/medicaid/covid19/index.htm.

"Emergency Services Only" Coverage

NYS Medicaid coverage for undocumented immigrants is limited to emergency services only. COVID19 lab testing, evaluation, and treatment are emergency services and will be reimbursed by NYS Medicaid for individuals with coverage code "07". Claims submitted for COVID-19 tests and practitioner office visits for the purpose of COVID-19 testing, evaluation, and/or treatment should be identified as an emergency by reporting Emergency Indicator = Y. Institutional providers (emergency department, hospital outpatient/diagnostic and treatment center, FQHC, and hospital inpatient) should report Type of Admission Code = 1 to indicate an emergency when the purpose of the visit is for testing, evaluation, and/or treatment related to COVID-19. There is no copay for emergency services including testing, evaluation, and treatment for COVID-19.

Prevention

COVID-19 can be spread from infected individuals to others through close personal contact and through the air by coughing and sneezing. Providers should encourage their patients to practice good hand washing, avoid touching their faces as much as possible, and avoid unnecessary contact with individuals who are ill.

Additional guidance can be found on the following CDC websites:

Questions

  • Medicaid Fee-for-Service (FFS) coverage and policy questions should be directed to the Office of Health Insurance Programs (OHIP), Division of Program Development and Management at (518) 473‑2160 or FFSMedicaidPolicy@health.ny.gov.
  • Medicaid Managed Care (MMC) general coverage questions should be directed to the OHIP, Division of Health Plan Contracting and Oversight at: covques@health.ny.gov or (518) 473‑1134.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to the enrollee´s MMC plan.
  • FFS claim questions should be directed to the eMedNY Call Center at (800) 343‑9000.