New federal guidance seeks to clarify reimbursement of COVID-19 testing and vaccinations

Federal agencies have issued new guidance intended to make it easier for healthcare providers to be reimbursed for administering COVID-19 tests to insured individuals and for providing testing and vaccinations to the uninsured.

Portions of the guidance prohibit group health plans from imposing restrictions on coverage of testing, regardless of the circumstances of the test.

“This guidance makes clear that private group health plans and issuers generally cannot use medical screening criteria to deny coverage for COVID-19 diagnostic tests for individuals with health coverage who are asymptomatic and who have no known or suspected exposure to COVID-19,” CMS states in a news release.

As long as such testing is administered or referred by a licensed or authorized healthcare provider, it “must be covered without cost sharing, prior authorization or other medical management requirements imposed by the plan or issuer.”

Reimbursement for providing the vaccine to uninsured individuals

The guidance notes that federal funding is available to compensate providers for administering COVID-19-related services — including testing and vaccination — to the uninsured.

The Provider Relief Fund makes funding available through the COVID-19 Uninsured Program, which has disbursed $3 billion for COVID-19 testing and treatment of uninsured individuals and which “expects to see vaccine administration claims as states scale up their vaccination efforts,” CMS states.

Providers who receive payments from the COVID-19 Uninsured Program “cannot seek reimbursement, including balance billing, for such vaccination, care, or treatment from the individual or any other source,” the guidance states.