Highmark Updates Tied to End of Public Health Emergency
On January 30, 2023, the federal government announced the May 11, 2023, expiration of the COVID-19 public health emergency (PHE).
In response to the COVID-19 pandemic and pandemic-related laws, Highmark implemented many policies and flexibilities waiving or requiring certain actions in response to the pandemic’s effect on health care delivery.
To help providers transition to a post-PHE environment, providers will have 90 days to prepare for Highmark’s policy changes and insurance plans/product updates listed below to take effect on July 6, 2023.
Liability immunity has been extended to providers based on the Public Readiness and Emergency Preparedness (PREP) Act to allow for greater delivery of and access to medical countermeasures. These protections will expire on October 1, 2024.
Note: Some state mandates regarding COVID-19 will still be in place once the federal PHE ends. Highmark will follow all federal and state regulations regarding COVID-19 policies.
With the expiration of the PHE, Highmark has started the process of updating COVID-19-impacted policies and procedures including:
COVID-RELATED CARE – COST SHARE WAIVERS WILL SUNSET
Highmark will extend the following waivers to Highmark members with employer-sponsored or individual health insurance coverage through May 31, 2023*:
- $0 in-network and out-of-network COVID-19 vaccines
- $0 in-network and out-of-network COVID-19 diagnostic and antibody testing
- $0 over the counter (OTC) COVID-19 testing
- $0 prescription antiviral treatment
- $0 in-network and out-of-network related services to diagnose COVID-19 – office visit (in-person or telehealth), emergency room or urgent care
For Medicare Advantage (MA) members, Highmark will extend the following waivers with Highmark MA insurance coverage through May 31, 2023*:
- $0 in-network and out-of-network COVID-19 vaccines
- $0 in-network and out-of-network COVID-19 diagnostic and antibody testing
- $0 in-network and out-of-network related services to diagnose COVID-19. Includes office visits (in-person or telehealth), emergency room visits or urgent care visits.
- $0 inpatient COVID-19 treatment – covered through December 31, 2023, for Medicare Advantage members
West Virginia: Cost share waiver mandates related to lab testing, OTC tests, and vaccinations may continue to be in place after the federal PHE ends.
*While this coverage applies to most Highmark members, every plan is a little different. If members have any questions, they should login to their member portal and send a message using the message center to Member Service. Members can also call Member Service using the number on the back of their insurance card.
After June 1, 2023, the services above may have out-of-pocket costs based on member plan coverage.
RETAIL TESTS
Over the counter COVID-19 tests will no longer be covered, with members responsible for paying the full cost of these kits. Free tests from the federal government are available at www.covid.gov/tests until supplies run out.
TELEHEALTH FLEXIBILITIES – MANY TO REMAIN IN PLACE
Many telehealth flexibilities expanded during the PHE will remain in place. Virtual COVID-19-related care will be treated like any other telehealth service.
Reminder: For years prior to the PHE, Highmark had allowed the delivery of virtual visits by practitioners. Please see the Highmark Provider Manual, Chapter 2, Unit 5, for more information regarding the services that may be provided through this modality and other guidelines.
CHANGES EFFECTIVE JULY 6, 2023
Unless otherwise noted, the following policy changes will go in effect on July 6, 2023:
COVID-19 Non-OTC Diagnostic Tests Reimbursement
- Standardized pricing will be updated for CPT codes U0001 and U0002.
- Codes U0003 – U0005 will no longer be reimbursed as they are not eligible codes as of May 11, 2023.
Swabbing Codes for COVID Testing
- Commercial
- CPT codes 99000 and 99001 will no longer be reimbursed.
- Commercial and Medicare Advantage
- C9803 will continue to be reimbursed if billed separately with a member cost share.
- G2023 and G2024 will no longer be reimbursed as they are not eligible codes as of May 11, 2023.
Prior Authorization Policy
- The “Stabilize and Transfer” out-of-network protocol will be reinstated for all narrow network products.
- For West Virginia only: Existing state mandates will continue to be followed post-PHE.
- For Delaware only: Under the existing state mandate, insurers must continue to waive all prior authorization requirements for lab testing and treatment of confirmed or suspected COVID-19 patients.
Medical Policies
The following Medical Policies will be updated:
- M-74, Home Prothrombin Time INR Monitoring for Anticoagulation Management
- Y-5, Vision Therapy (Orthoptics and Pleoptics)
To review the Medical Policies, click on MEDICAL POLICY SEARCH in the gray Quick Links bar at the top of the Provider Resource Center.
CMS Disaster Memo: Paying All Out-Of-Network Claims as In-Network
- Medicare Advantage
- All OON claims will pay under filed OON plan design coverage rules after June 11, 2023, given CMS regulations.
Credentialing Policies
Providers in our network were given COVID-19 exceptions, such as not having a Drug Enforcement Agency (DEA) number for the state they are practicing in. These providers will now need to meet the expectations of our existing credentialing policies.
- For Delaware (DE) only: All credentialing exceptions related to the PHE will end, including those listed below:
- Out-of-state license for mental health providers.
- Out-of-state license if working in a hospital or long-term care facility.
- DE expired license, if expired within the last five years.
- DE facility expired license for mental health providers only.
REIMBURSEMENT POLICIES
Effective July 6, 2023, Telehealth and Virtual Health components for the following Reimbursement Policies (RP) will be removed:
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RP–010: Incident To Services
The supervising physician must be physically present. Virtual supervision will no longer be allowed.
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RP–027: Hemodialysis and Peritoneal Dialysis
Procedure codes 99401, 99402, 99403, 99404, 99411, and 99412, will no longer be eligible to be performed as telemedicine. Similarly, procedure codes, 99221, 99222 and 99223, will no longer be eligible to be performed as telemedicine.
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RP–041: Services Not Separately Reimbursed
The following procedure codes 90887, 99024, 99374, 99377, 99378, 99379, 99380 and 99483 will no longer be eligible to be performed as telemedicine.
New York will no longer reimburse for code U0005.
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West Virginia ONLY
RP–044: Medical Therapy Management Services
The note on this policy stating a pharmacist will be permitted to perform incident to billing services for the duration of the PHE will be removed.
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RP–046: Telemedicine and Telehealth Services
The provision that — Eligible Providers performing and billing telehealth services must be eligible to independently perform and bill the equivalent face-to-face service — is being reinstated.
Additional COVID-19-related language will be removed effective May 29, 2023.
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OTHER REIMBURSEMENT CHANGES – EFFECTIVE JULY 6, 2023
You can review all current Reimbursement Policies on the Provider Resource Center. Click on CLAIMS, PAYMENT & REIMBURSEMENT from the left menu and scroll down to Reimbursement Policy.
ADDITIONAL CHANGES
PHARMACIST ADMINISTERED COVID-19 TESTING
Many states expanded the scope of practice for pharmacists to include this type of testing. Continued pharmacist testing will be dependent on whether these changes are made permanent at a state level.
Clinical Laboratory Improvement Amendments (CLIA) waivers are needed by pharmacies to perform this type of testing. Pending additional CMS guidance for post-PHE expectations.
- For Delaware only: Highmark is currently implementing a mandate to allow pharmacists to perform COVID-19 testing.
TIMELY REQUIREMENTS
Highmark will resume application of standard deadlines for the following items 60 days after the end of the PHE:
- Requests for both internal (conducted by Highmark) and external appeals regarding adverse benefit determinations
- Timeframes for filing claims
Additional information on Timely Requirements can be found in the Highmark Provider Manual: Chapter 6, Unit 1 - General Claim Submission Guidelines.
ENDING OF 20% INCREASE IN DRG WEIGHT APPLIED TO COVID-19 DISCHARGES
- For New York (NY) only: NY will revert to current contractual reimbursement schedules. Timeline will be based on our contractual obligations. Facilities will receive, at a minimum, a 60-day notice.
MEMBER NOTIFICATION
Highmark members were notified of changes related to coverage and cost share waivers through our website on March 22, 2023. These changes will affect members starting June 1, 2023. For additional information on these changes, visit highmarkanswers.com.
MEDICAID REDETERMINATION
Income eligibility requirements for Medicaid were waived during the PHE to help millions of Americans who lost their employer-sponsored health insurance. The continuous enrollment requirement ended on March 31, 2023, establishing the date of April 1, 2023, for resuming Medicaid redetermination.
Beneficiaries will need to recertify their eligibility for Medicaid to maintain coverage. As states begin reviewing eligibility requirements, some enrollees currently on the Medicaid program will be found ineligible and will need to transition to other health insurance coverage.
Last updated on 5/17/2023 1:05:42 PM