COVID-19 Guide for Patients and Providers
Summary
As our healthcare industry rapidly evolves to address the COVID-19 pandemic, keep track of new resources and policies affecting patients and providers with the COVID-19 guide below.
Please note: This is an archived post. Some of the information and data discussed in this article may be out of date. It is preserved here for historical reference but should not be used as the basis for business decisions. Please see our main Insights section for more recent posts.
Last updated August 31, 2020.
Topics
- Patient Affordability
- Care Delivery
- Provider Reimbursement
- Utilization Management
- Other
- Additional Resources
| Topic | Description | Timelines | Source(s) of Authority | Resources |
|---|---|---|---|---|
| Cost Sharing for COVID-19 Testing | Medicaid/Medicare: New cost-sharing requirements for COVID-19 testing have been established for Medicare, MA, and Medicaid. CMS has placed limits on the number of COVID-19 tests per beneficiary that are covered by Medicare without an order from a pharmacist or other practitioner. | Lasts for duration of the national public health emergency | Family First Coronavirus Response Act Third Interim Final Rule: Additional Policy and Regulatory Revisions in Response to the COVID-19 Emergency |
CMS FAQs for state Medicaid agencies on FFCRA and the CARES Act |
| Commercial: New cost-sharing requirements for COVID-19 testing have been established for commercial health plans. | Lasts for the duration of the national public health emergency | Family First Coronavirus Response Act | AHIP list of commercial insurers’ COVID-19 policies CMS FAQs on commercial coverage of testing |
|
| Uninsured: Funds have been set aside by Congress for testing the uninsured. Some states may cover testing for the uninsured under their Medicaid programs. | N/A | Paycheck Protection Program and Healthcare Enhancement Act Family First Coronavirus Response Act |
CMS FAQs for state Medicaid agencies on FFCRA and the CARES Act HRSA guide for COVID-19 testing and treatment for the uninsured | |
| Cost Sharing for COVID-19 Treatment | Medicare: Patients in traditional Medicare may be subject to standard Medicare cost sharing, including any supplemental coverage, for treatment. New cost-sharing requirements and flexibilities have been established for MA plans. |
Changes to MA requirements last for duration of the national public health emergency | CMS Memo to MAOs and Part D Sponsors | Medicare cost sharing at a glance CMS overview of Medicare and COVID-19 KFF FAQs on Medicare coverage and costs related to COVID-19 |
| Medicaid: New cost-sharing requirements have been established for states who accept increased federal matching funds under the Family First Coronavirus Response Act. | Lasts for duration of the national public health emergency | Family First Coronavirus Response Act | CMS FAQs for Medicaid Agencies on FFCRA Coverage and benefits for COVID-19 related to Medicaid and CHIP |
|
| Commercial: Some private insurers have committed to altering cost sharing for COVID-19 treatment. Additionally, some states have established commercial plan requirements for cost sharing. | N/A | Commercial payer discretion and state authority | AHIP list of commercial insurers’ COVID-19 policies KFF overview of state COVID-19 policy actions |
|
| Cost Sharing for Telehealth Services | Medicare: New flexibilities have been given to Medicare providers to alter cost-sharing obligations for telehealth services in federal healthcare programs. Additional cost-sharing flexibilities have been provided to MA plans. | Lasts for duration of the national public health emergency | First Interim Final Rule: Response to the COVID-19 Public Health Emergency OIG Ruling on Cost Sharing for Telehealth Services CMS Memo to MAOs and Part D Sponsors |
Medicare coverage of telehealth KFF FAQs on Medicare coverage and costs related to COVID-19 |
| Medicaid: Some states have altered cost-sharing requirements and changed Medicaid coverage for telehealth services. | Varies; most changes end with the duration of the national public health emergency and/or state-declared emergencies | State Plan Amendments State Executive Orders |
State Medicaid telehealth toolkit CMS FAQs for state Medicaid agencies on FFCRA and the CARES Act |
|
| Commercial: Some state executive orders have established new cost sharing requirements for commercial health plans. Additionally, some private insurers have announced that they are independently altering cost sharing standards for telehealth services. | Varies; most changes end with the duration of the national public health emergency or state-declared emergencies | State Executive Orders | AHIP list of commercial insurers’ COVID-19 policies APTA summary of state actions related to telehealth Forbes list of state actions |
|
| Premium Payment Flexibilities | Medicaid: Several states have been approved for state plan amendments that change premium and enrollment fee requirements for Medicaid beneficiaries. | Lasts for the duration of the national public health emergency | State Plan Amendments | KFF overview of state COVID-19 policy actions |
| Commercial: New flexibilities have been established for individual plans, small group plans, and ACA exchanges to alter premium payment requirements. Some state executive orders have made changes to premium payment policies for commercial health plans. | Lasts for the duration of the national public health emergency | CMS Guidance to Plans on the Federally-Facilitated or State-based Exchanges CMS Announcement on Temporary Policy for Premium Reductions |
KFF overview of state COVID-19 policy actions |
| Topic | Description | Timelines | Source(s) of Authority | Resources |
|---|---|---|---|---|
| Telehealth Flexibilities | Medicare: New policies have been established that change traditional Medicare coverage for telehealth services and create additional provider flexibilities. MA plans have been encouraged to change existing telehealth requirements. |
Lasts for the duration of the national public health emergency; some changes likely to be made permanent | First Interim Final Rule: Response to the COVID-19 Public Health Emergency Coronavirus Preparedness and Response Supplemental Appropriations Act CMS Memo to MAOs and Part D Sponsors Second Interim Final Rule: Response to the COVID-19 Public Health Emergency President Trump’s Telehealth Executive Order |
KFF FAQs on Medicare coverage and costs related to COVID-19 Medicare telemedicine provider fact sheet HHS report on COVID-19 Medicare telehealth utilization Business Group on Health’s strategies for expanding telemedicine |
| Medicaid: Telehealth policies vary across state Medicaid agencies. Some states have changed policies related to telehealth coverage and flexibilities. | Varies by state | State Medicaid programs | State Medicaid telehealth toolkit CCHPCA list of COVID-19 state telehealth actions |
|
| Commercial: Some commercial payers have expanded telehealth coverage policies. | Varies by payer | Commercial payer discretion | AHIP list of commercial insurers’ COVID-19 policies | |
| Home Health Flexibilities | Medicare: New flexibilities have been established to expand coverage under the Medicare Home Health Benefit and relax certain requirements for providers and home health agency staff to administer services in the home setting. | The duration of the public health emergency | First Interim Final Rule: Response to the COVID-19 Public Health Emergency Second Interim Final Rule: Response to the COVID-19 Public Health Emergency |
CMS home health agency guidance |
| Medicaid: A subset of states have submitted waivers to modify home health requirements and expand coverage for services. | Varies by state | Section 1915(c) waivers | COVID-19 frequently asked questions for state Medicaid agencies | |
| Home Infusion Flexibilities | Medicare: Providers and home health agencies have been granted new flexibilities to administer drugs in the home setting. | The duration of the public health emergency | First Interim Final Rule: Response to the COVID-19 Public Health Emergency | CMS COVID-19 provider guide FDA home infusion pump guidance |
| Topic | Description | Timelines | Source(s) of Authority | Resources |
|---|---|---|---|---|
| Reimbursement for COVID-19 Testing | Medicare: Medicare Administrative Contractors (MACs) have established reimbursement rates for high-throughput COVID-19 testing methods, the CDC-developed test, and other COVID-tests. The CMS has created new flexibilities related to Medicare and MA provider payment for COVID-19 testing. | Permanent | CMS Ruling on COVID-19 Testing Reimbursement Second Interim Final Rule: Response to the COVID-19 Public Health Emergency |
CMS’s Medicare provider FAQ MAC COVID-19 test pricing chart |
| Commercial: Specific provider reimbursement standards for COVID-19 testing have been established for commercial plans. | Permanent | CARES Act | CMS FAQs on commercial coverage of testing | |
| Uninsured: A special reimbursement process has been established, based on Medicare payment rates, for providers who have conducted COVID-19 testing for uninsured patients. | Providers that submit claims can begin receiving reimbursement in mid-May | CARES Act Family First Coronavirus Response Act |
HRSA guide for COVID-19 testing and treatment for the uninsured | |
| Reimbursement for COVID-19 Treatment | Medicare/Medicaid/Commercial: Standard provider reimbursement for outpatient and inpatient services generally applies to COVID-19 treatment. The CMS has changed payment rules related to services provided in non-traditional settings and high-capacity healthcare facilities. | Permanent | Second Interim Final Rule: Response to the COVID-19 Public Health Emergency | CMS coverage and payment related to COVID-19 Medicare ASCO overview of COVID-19 government, reimbursement and regulatory updates |
| Uninsured: A special reimbursement process has been established, based on Medicare payment rates, for providers who have conducted COVID-19 testing for uninsured patients. | Providers that submit claims can begin receiving reimbursement in mid-May | CARES Act Family First Coronavirus Response Act |
HRSA guide for COVID-19 testing and treatment for the uninsured | |
| Accelerated and Advanced Medicare Payments | Medicare: The CMS has made changes to the Accelerated and Advance Medicare Payment Program for Part A and Part B providers. | Lasts for the duration of the national public health emergency | CARES Act CMS Announcementannouncement on Suspending the Accelerated and Advanced Payment Program |
CMS fact sheet on accelerated and advanced payments |
| Reimbursement for Telehealth | Medicare: New regulations have changed provider reimbursement for telehealth visits, allowed new provider flexibilities, altered hospital billing for telehealth services, and established new telehealth CPT codes. | Lasts for the duration of the national public health emergency; some likely to be made permanent. | First Interim Final Rule: Response to the COVID-19 Public Health Emergency Coronavirus Preparedness and Response Supplemental Appropriations Act Second Interim Final Rule: Response to the COVID-19 Public Health Emergency |
Medicare telemedicine provider fact sheet Business Group on Health’s strategies for expanding telemedicine |
| Medicaid: Telehealth reimbursement policies vary from state to state. Some state Medicaid programs have changed coverage and reimbursement for telehealth services. | Varies by state | State Medicaid Programs | State Medicaid telehealth toolkit CMS bulletin on Medicaid telehealth |
|
| Commercial: Reimbursement for telehealth services varies by commercial payer. Some commercial payers have changed telehealth coverage requirements and/or adjusted provider reimbursement rates. | Varies by payer | Commercial Payer Discretion | AHIP list of commercial insurers’ COVID-19 policies | |
| Provider Relief Funding | General relief funding has been allotted for Medicare providers and facilities, hospitals in high impact areas, rural providers, and other healthcare entities impacted by COVID-19. | N/A | CARES Act Paycheck Protection Program and Healthcare Enhancement Act |
Distribution of CARES Act Provider Relief Fund Provider Relief Fund terms and conditions HHS update on distribution of payments HHS update on timeline for additional payments from Provider Relief Fund Compliance deadline extension for providers HHS announcement on funding for Medicaid providers and safety net hospitals HRSA Medicaid and CHIP Provider Relief Fund Distribution fact sheet HHS July announcement on additional provider relief funding for safety net hospitals, rural providers and dentists HHS extension of application deadline for provider relief fund |
| Balance Billing | Certain requirements related to limiting balance billing for COVID-19 services have been established for providers who accept money from the CARES Act’s Provider Relief Fund. | N/A | Provider Relief Fund Terms and Conditions | Distribution of CARES Act Provider Relief Fund |
| Topic | Description | Timelines | Source(s) of Authority | Resources |
|---|---|---|---|---|
| Prior Authorization for COVID-19 Testing | Medicare/Medicaid/Commercial: Requirements related to prior authorization have been established for payers’ coverage of COVID-19 testing. | Lasts for the duration of the national public health emergency | Family First Coronavirus Response Act | CMS FAQs on commercial coverage of testing |
| Prior Authorization for Prescription Drugs | Medicare: The CMS has provided guidance to Part D sponsors and Medicare Advantage (MA) organizations on altering prior authorization for prescription drugs. | Permanent | CMS Memo to MAOs and Part D Sponsors | ASCO overview of COVID-19 government, reimbursement and regulatory updates |
| Medicaid: Many states have temporarily changed Medicaid prior authorization requirements for prescription drugs. | Varies; most changes end with the duration of the national public health emergency and/or state-declared emergencies | 1135 Waiver Amendments Approved State Plan Amendments |
KFF overview of state COVID-19 policy actions | |
| Commercial: Some health plans have extended existing prior authorizations for prescription drugs or adopted additional utilization management flexibilities. | Varies by payer | Commercial payer discretion | AMA prior authorization policy changes related to COVID-19 |
| Topic | Description | Timelines | Source(s) of Authority | Resources |
|---|---|---|---|---|
| Provider Liability | New liability protections have been established for health professionals who provide services during the COVID-19 emergency. | Lasts for the duration of the national public health emergency | CARES Act | AMA overview of liability protections during COVID-19 CMS announcement on new reporting guidelines |
| Provider Practicing Flexibilities | New flexibilities have been granted to allow some healthcare professionals to practice outside their normal operations, and to change requirements related to the direct supervision of procedures. The CMS has also relaxed facility requirements to allow increased hospital capacity and enable the provision of healthcare services in certain non-traditional medical facilities. Additionally, many states have changed out-of-state licensing requirements for providers. Additionally, pharmacists have been given new authority to administer certain childhood vaccines. | Lasts for the duration of the national public health emergency | First Interim Final Rule: Response to the COVID-19 Public Health Emergency CMS Guidance on Maximizing Frontline Healthcare Workforce Second Interim Final Rule: Response to the COVID-19 Public Health Emergency |
CMS physician and clinician flexibilities |
| Quality Reporting | Medicare: CMS has changed reporting requirement timelines and financial methodologies for CMS Innovation Center (CMMI) models and for multiple quality measure and value-based purchasing programs, including the Medicare Shared Savings Program. | Varies by CMS program | CMS Memo: HHS Postponement of HHS-RADV First Interim Final Rule: Response to the COVID-19 Public Health Emergency CMS Announcement on New Reporting Guidelines Second Interim Final Rule: Response to the COVID-19 Public Health EmergencyCMS Announcement on Adjustments to CMMI ModelsThird Amendment to Declaration Under Public Readiness and Emergency ActThird Interim Final Rule: Additional Policy and Regulatory Revisions in Response to the COVID-19 Emergency |
AMA overview of liability protections during COVID-19 |
| Prescription Drug Access Flexibilities | Medicare: New requirements have been established related to Part D sponsors’ refill and drug supply policies. Additional permissions have been granted to support mail or home delivery for retail pharmacies. | Lasts for the duration of the national public health emergency | CARES Act CMS Memo to MAOs and Part D Sponsors |
CMS PDP and MA-PD COVID-19 flexibilities |
| Clinical Trials | The FDA has provided guidance on conducting clinical trials during the pandemic to help sponsors determine when shifts to alternative settings or trial discontinuation may be appropriate. The Coronavirus Treatment Acceleration Program (CTAP) has been established to expedite the development of safe and effective treatments for COVID-19. | Lasts for the duration of the national public health emergency | FDA Guidance on Conducting Clinical Trials on Medical Products During Pandemic CTAP | NIH’s Clinicaltrials.gov |
| Non-Essential Surgeries and Procedures | The CMS has released guidance on conducting non-essential procedures and on the operating status of healthcare facilities during the pandemic. States have the ultimate authority to decide whether to resume elective procedures. | Dependent on individual state reopening plans | CMS Non-Emergent, Elective Medical Services and Treatment Recommendations CMS Recommendation for Re-opening Facilities |
ASCA overview of state guidance on elective surgeries |
Additional Resources
- AMA COVID-19 Resource Center for Physicians
- Avalere COVID-19 Intel Center
- CMS COVID-19 Partner Toolkit
Additional Resources for Telehealth
- ACG Essential Guide for Telemedicine
- ACR COVID-19 Practice and Advocacy Resources
- ADA TeleDermatology Toolkit
- AGA Coverage and Coding for Telehealth and eVisits during the COVID-19 Crisis
- APA Telepsychiatry Toolkit
- AUA Telehealth Resources
- Business Group on Health Telemedicine Guide
- TeleHealthHIV
Resources Specific to Therapeutic Area
- American Academy of Dermatology Association
- American College of Gastroenterology
- American College of Rheumatology
- American Gastroenterology Association
- Arthritis Foundation
- Crohn’s & Colitis Foundation
- Community Oncology Alliance
- National Infusion Center Association
- National Organization of Rheumatology Managers
- National Psoriasis Foundation
- Spondylitis Association of America
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