SPECIAL BULLETIN COVID-19 #268: COVID-19 Testing, Vaccination and Counseling Coverage After the Federal Public Health Emergency

This bulletin provides consolidated information on the coverage of COVID-19 over-the-counter tests for home use, COVID-19 vaccine enhanced reimbursement and COVID-19 vaccine counseling now that the federal Public Health Emergency (PHE) has ended, as of May 11, 2023.

The Centers for Medicare and Medicaid Services (CMS) has issued guidance related to coverage of certain COVID-19 vaccines, counseling, and related treatment to be provided under the American Rescue Plan Act of 2021 (ARPA) (Pub. L. No. 117-2).

ARPA requires state Medicaid programs to cover COVID-19-related treatments (including treatment of conditions that may seriously complicate the treatment of COVID-19) without cost-sharing. Additionally, ARPA requires that Medicaid cover specific treatments through one year and one quarter after the end of the federal Public Health Emergency, which is Sept. 30, 2024. The guidance in this bulletin applies to both NC Medicaid Direct and NC Medicaid Managed Care.

COVID-19 Vaccines Reimbursement

NC Medicaid will reimburse at the Medicare-approved COVID-19 vaccination administration rate of $65 until Sept. 30, 2024. Effective Oct. 1, 2024, reimbursement for COVID-19 vaccine administration will align with the standard administration rate per COVID-19 vaccine dose.

For Medicaid Billing

• The ICD-10-CM diagnosis code(s) required for billing is/are: Z23 - Encounter for immunization.
• Providers must bill with the correct HCPCS codes for the COVID-19 vaccine administered.
• The maximum reimbursement rate per unit is: $0.00 for COVID vaccines.
• Providers must bill 11-digit NDCs and appropriate NDC units for the COVID-19 vaccine administered.

Important Claims Information

• NC Medicaid will reimburse at the Medicare-approved COVID-19 vaccination administration rate of $65 until Sept. 30. 2024.
• Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code.
• Claims must contain both administration codes and vaccine codes to pay.
• Vaccine codes should be reported as $0.00.
• Copays may not be charged for COVID-19 immunization or administrations.
• COVID-19 vaccines are exempt from the Vaccines For Children (VFC) program.
• EP modifier should be appended for all NC Medicaid beneficiaries younger than age 21.
• CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program.

COVID-19 Vaccine Counseling Coverage

NC Medicaid recognizes the importance of vaccinating Medicaid beneficiaries against COVID-19. NC Medicaid continues to encourage providers to work with their patients to receive COVID-19 vaccines.

The coverage for COVID-19 Vaccine Counseling (CPT 99401) for adults 21 and older ended with the end of the federal PHE on May 11, 2023.

NC Medicaid will continue to cover COVID Counseling for members who are under age 21 until Sept. 30, 2024, per guidance from CMS and consistent with EPSDT.

NC Medicaid understands the additional administrative responsibilities COVID-19 places on Medicaid providers due to providing the vaccine in your offices and the additional time it takes for counseling and informed consent, as well as post-vaccine observation. NC Medicaid is pleased to continue to offer vaccine counseling for members under age 21 until Sept. 30. 2024 to encourage access to COVID-19 vaccines for children.

For COVID-19 vaccine counseling, providers should continue to leverage CPT 99401 when counseling members under age 21.

CPT 99401: Preventative medicine counseling and/or risk factor reduction intervention(s) provided to an individual, up to 15 minutes has been added to counsel Medicaid beneficiaries regarding the benefits of receiving the COVID-19 vaccine.  

Note: COVID-19 Counseling is available for all NC Medicaid beneficiaries under age 21, both Medicaid Direct and Medicaid Managed Care.

CPT 99401 can be billed at only one visit for each beneficiary per day, but there are no quantity limits for the number of times this education can be provided to an individual beneficiary. Counseling may be provided in person, through live audio/video (telehealth) or telephonically. Additionally, this service can be billed by multiple providers and can be billed multiple times on different days.

There is no requirement for a specific diagnosis code. The following coding criteria will apply:

• Requires 25 modifier if in addition to OV E&M, if applicable.
• Requires GT modifiers if provided via telehealth.
• Requires KX modifiers if provided telephonically.

Providers are encouraged to counsel Medicaid beneficiaries of any age, but providers will only be reimbursed for counseling members under age 21. Parents can be counseled about giving the vaccine to their children age 6 months and over. Parents or guardians of Medicaid children can be counseled on the benefit of receiving the COVID-19 vaccination even if the parent or guardian is not enrolled in NC Medicaid. The counseling session for the parent or guardian can be billed to the child’s Medicaid ID, but only one code can be billed per day.

The service can only be provided by MD/DO, NP, PA, CNM and, if provided at LHD, FQHC or RHC by one of these professionals, will be reimbursed outside of the PPS rate. The coverage is time-limited and will end on Sept. 30, 2024, for NC Medicaid beneficiaries under age 21 (Medicaid Direct and Medicaid Managed Care).

Over-the-Counter Tests for Home Use Coverage for COVID-19

Reminder for NC Medicaid-enrolled  pharmacy providers

Point-of-sale (POS) billing for FDA-authorized over the counter (OTC) COVID-19 tests dispensed for use by NC Medicaid beneficiaries in a home setting remains in effect. COVID-19 OTC tests for home use are covered for full Medicaid enrollees through Sept. 30, 2024.

Coverage of one kit per claim per date of service is allowed up to a maximum of eight tests every rolling 30 days. The eight total tests could be mixed and matched between one-test kit or two-test kits to get a total of eight tests.

Since a State Standing Order is issued for the OTC COVID-19 test for home use, tests may be dispensed under State Health Director and Chief Medical Office Dr. Elizabeth Cuervo Tilson’s National Provider Identifier (NPI), with or without a prescription issued by an active NC Medicaid enrolled provider. Alternatively, the claim may be submitted using the pharmacy’s NPI or the prescriber’s NPI if prescribed by a Medicaid-enrolled provider.

Pharmacies must follow the National Council for Prescription Drug Programs (NCPDP) standard and use the National Drug Code (NDC) found on the package. Reimbursement is at an NDC-specific State Maximum Allowable Cost (SMAC). Copayment does not apply.

Covered test kits with the SMAC are listed below. Effective dates are for NC Medicaid Direct claims. Please refer to the beneficiary’s health plan for effective dates, as dates could be different.

Contact

NCTracks Call Center: 800-688-6696