NCOV -19 and MEDICARE 2020

Medicare Part B, which includes a variety of outpatient services cover medically necessary clinical diagnostic laboratory tests when a doctor or other practitioner orders them.

Medically necessary clinical diagnostic laboratory tests are generally not subject to coinsurance or deductible. It will cover medically necessary imaging tests, such as computed tomography (CT) scans, as needed for treatment purposes for lung infections, however not for screening asymptomatic patients.

For those imaging tests paid by Part B, beneficiary coinsurance and deductible would apply. If the Part B deductible ($198 in 2020) applies to the Part B services, beneficiaries must pay all costs - up to the approved amount of Medicare until the beneficiary meets the yearly Part B deductible. Once it is met, Medicare pays its share, and beneficiaries typically pay 20% of the approved amount of the service, except laboratory tests. There’s no yearly limit for what a beneficiary pays out-of-pocket though.

There was public health news alert  issued by CMS on February 13th, which has additional information about the new Healthcare Common Procedure Coding System (HCPCS) for health care providers and laboratories to bill for a laboratory testing patients.

HCPCS 

It is a standardized coding system that Medicare and other health insurers use to submit claims for services provided to patients. This code will allow those laboratories conducting the tests to bill for the specific test instead of using an unspecified code, which means better tracking of the public health response for this particular strain of the coronavirus to help protect people from the spread of this infectious disease. 

There are two new HCPCS codes for healthcare providers who need to test patients for Coronavirus. Providers using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real-Time RT-PCR Diagnostic Test Panel may bill for that test using the newly created HCPCS code (U0001) and HCPCS code (U0002) generally describes 2019-nCoV Coronavirus, SARS-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types, or subtypes which includes all targets. The Medicare claims processing system will be able to accept these codes on April 1, 2020 for dates of service on or after February 4, 2020.

Inpatient Hospital Care Services Medicare 

Part A 

It covers medically necessary inpatient hospital care. This coverage includes semi-private rooms, meals, general nursing, imaging, drugs as well as other hospital services and supplies as part of inpatient hospital treatment. Inpatient hospital treatment includes care from acute care hospitals, critical access hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care as part of a qualifying clinical research study.

Under Original Medicare, for hospital inpatient services, beneficiaries pay a deductible of $1,408 and no coinsurance for days 1– 60 of each benefit period. Beneficiaries pay a coinsurance amount of $352 per day for days 61– 90 of each benefit period. There is a coinsurance amount per “lifetime reserve day” after day 90 of each benefit period. Then beneficiaries pay all costs for each day after all the lifetime reserve days are used. Patients who would have been otherwise discharged from the hospital after an inpatient stay but instead remain in the hospital under quarantine would not have to pay an additional deductible. If a Medicare beneficiary is a hospital inpatient for medically necessary care, Medicare will pay hospitals the diagnosis-related group (DRG) rate and any cost that occur for the entire stay, including any the quarantine time when the patient does not meet the need for acute inpatient care, until the Medicare patient is discharged. The DRG rate includes payments for when a patient needs to be isolated or quarantined in a private room.

Ambulatory Services in a Hospital or Other Location Medicare Part B 

It covers medically necessary ambulatory services, including doctors’ services, hospital outpatient department services, home health services, durable medical equipment, mental health services, and other medical services. Coinsurance and deductible would generally apply depending on the service. In the event, a patient is quarantined in an ambulatory setting, the existing Medicare payments for medically necessary services apply. 

Telehealth and Other Communication-Based Technology Services Beneficiaries 

It can communicate with their doctors or certain other practitioners without necessarily going to the doctor’s office in person for a full visit. Since 2018, Medicare pays for virtual check-in for patients to connect with their doctors without going to the doctor’s office. These brief, virtual check-in services are for patients with an established relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours. The patient must verbally consent to use virtual check-ins and the consent must be documented in the medical record prior to the patient using the service. The Medicare coinsurance and deductible would apply to these services. Doctors and certain practitioners may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010). The Medicare coinsurance and deductible would apply to these services.

Emergency Ambulance Transportation 

Medicare 

It covers the ground ambulance transportation when beneficiaries need to be transported to a hospital, critical access hospital, or skilled nursing facility for medically necessary services when transportation in any other vehicle could endanger the beneficiary’s health. 

Also, Medicare may pay for emergency ambulance transportation in an airplane or helicopter to a hospital if the beneficiaries need immediate and rapid ambulance transportation that ground transportation can’t provide. Should a facility which would normally be the nearest appropriate facility be unavailable during an emergency, Medicare may pay for transportation to another facility so long as that facility is the nearest that is available and equipped to provide the needed care for the illness or injury involved. 

In some cases, Medicare may pay for limited, medically necessary, nonemergency ambulance transportation if the doctor writes an order stating that ambulance transportation is medically necessary. There is a current Medicare model testing prior authorization for individuals receiving scheduled, nonemergency ambulance transportation for 3 or more round trips in a 10-day period or at least once a week for 3 weeks or more in certain states. The Medicare coinsurance and deductible would apply to these Part B services. Medicare pays for ambulance transports under the Ambulance Fee Schedule. This payment amount includes a base rate payment (level of service provided) plus a separate payment for mileage to the nearest appropriate facility and also cover both the transport of the beneficiary to the nearest appropriate facility and all medically necessary covered items and services associated with the transport.

Medicare Advantage (Part C) and Part D 

Medicare Advantage 

It is an all in one alternative to Original Medicare. Medicare Advantage plans cover Medicare Part A and Part B services, and usually prescription drugs covered under Medicare Part D. These plans also may offer extra benefits Original Medicare doesn’t cover.

Medicare Advantage plans must cover all medically necessary Part A and B services covered under Original Medicare for all enrollees and also, all items and services beyond those covered by Original Medicare. 

Additionally, CMS advises Medicare Advantage organizations that they may waive or reduce enrollee cost-sharing for Novel Coronavirus (COVID-19) laboratory tests effective immediately provided that MA organizations waive or reduce cost-sharing for all plan enrollees on a uniform basis. Specifically, CMS will exercise its enforcement discretion regarding the administration of MA organizations benefit packages as approved by CMS in conjunction with implementing a voluntary waiver or reduction of cost-sharing for COVID-19 laboratory tests as described. 

Telehealth and other Communication Based Technology Services Medicare Advantage plans may provide their enrollees with access to Medicare Part B services via telehealth in any geographic area and from a variety of places, including beneficiaries’ homes. With this flexibility, it is possible that beneficiaries in Medicare Advantage plans can receive clinically appropriate services for the treatment of COVID-19 via telehealth.

Part D Coverage

Each Part D Sponsor that offers prescription drug coverage must provide a standard level of coverage to ensure beneficiaries have adequate access to Part D drugs. Vaccines under current law, once a vaccine becomes available for COVID-19, Medicare will cover the vaccine under Part D. All Part D plans will be required to cover the vaccine. Prior Authorization Consistent with flexibilities available to Medicare Advantage Organizations and Part D Sponsors with respect to other items and services, they may choose to waive the plan prior authorization requirements that otherwise would apply to tests or services related to COVID-19.