SPECIAL BULLETIN COVID-19 #259: Mandatory Coverage of COVID-19-Related Treatment Under the American Rescue Plan Act of 2021 (UPDATE)

Guidance for NC Medicaid Direct and NC Medicaid Managed Care

This bulletin replaces SPECIAL BULLETIN COVID-19 #255 in its entirety, as it has been updated to provide clarity on the copay requirements for pharmacological treatments including, but not limited to, the impacted diagnoses.  

The Centers for Medicare and Medicaid Services (CMS) has issued guidance for COVID-19-related treatment to be provided under the American Rescue Plan Act of 2021 (ARPA) (Pub. L. No. 117-2). ARPA requires state Medicaid and CHIP (NC Health Choice) programs to cover COVID-19-related treatments (including treatment of conditions that may seriously complicate the treatment of COVID-19) without cost-sharing. This guidance and the changes listed in this bulletin apply to both NC Medicaid Direct and NC Medicaid Managed Care. 

Additionally, under these amendments, beginning March 11, 2021, state Medicaid and separate CHIP programs must cover the treatment of a condition that may seriously complicate the treatment of COVID-19, if otherwise covered under the state plan (or waiver of such plan, including a section 1115 demonstration) during the period individuals who are diagnosed with or presumed to have COVID-19.  

The State is not requiring past claims to be reprocessed by providers. These coverage requirements and cost-sharing prohibitions generally end on the last day of the first calendar quarter, which begins one year after the last day of the COVID-19 emergency period described in section 1135(g)(l)(B) of the Act (i.e., through the last day of the COVID-19 public health emergency (PHE). For example, if the federal PHE were to end Oct. 14, 2022, this would be in effect through March 31, 2024.). 

Pharmacological Treatments 

Medications necessary for the treatment of COVID-19 and treatment of conditions that may seriously complicate the treatment of COVID-19 will be provided without cost-sharing. Beneficiaries should not be charged a copayment for these medications during the period when a beneficiary is diagnosed with or is presumed to have COVID-19.  

This includes drugs covered by the State as of March 11, 2021. Medications are provided to beneficiaries without cost sharing pursuant to section 1916(a)(2)(l) and 1916A(b)(3)(B)(xiii) of the Act. Reimbursement to qualified providers for such coverage is not reduced by any cost sharing that would otherwise be applicable under the State Plan.  

Providers should indicate on the face of the prescription that the medication is used to treat COVID-19 or a condition which may seriously complicate the treatment of COVID-19. Covered medications may include, but are not limited to, medications such as antibiotics, inhalers and steroids used to treat COVID-19 or any condition that may seriously complicate the treatment of COVID-19. 

Pharmacy providers should enter a diagnosis code for COVID-19 on the point of sale claim to indicate the medication is being used for COVID-19. Application of this code will eliminate any cost sharing responsibility for the beneficiary. 

Non-Pharmacological Treatments 

Outpatient Specialized Therapies (AUD, OT, PT, RT, ST): 

Specialized Therapies (including preventive therapies) that are medically necessary for treatment of COVID-19 and post-COVID-19 conditions may be requested through the prior authorization process on a case-by-case basis. The request must consider the particular treatment needs of the individual and the judgment of the health care provider.  

Any limit typically placed on the amount, duration or scope of coverage of a service will not be applied if the service is covered under ARPA and is needed to treat COVID-19. This includes the annual adult limit of 27 visits for Speech, Occupational and Physical Therapy. The Respiratory Therapy (RT) visit and age limits will also not apply.  

The current 0-20 age restriction for respiratory therapy services under Clinical Coverage Policy 10D will be waived in this circumstance to provide treatment for COVID-19 and post-COVID-19 conditions for all ages.  

CONTACT

NC Medicaid Contact Center: 888-245-0179