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Provider Coronavirus Information

The Centers for Medicare and Medicaid (CMS) Release Billing Guidelines for COVID-19 Vaccine.

Buckeye Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidance (PDF) for Medicaid and Children’s Health Insurance Program (CHIP) providers.  Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. In addition:

  • Buckeye Health Plan will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration, in accordance with Ohio’s coverage determinations for Medicaid beneficiaries
  • Member liability will be $0
  • Non-participating provider pre-auth requirements will be waived
  • Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published as of December 21, 2020. However, they will not be billable until the specific vaccine receives official EUA approval.

Payment Allowances and Effective Dates for COVID-19 Vaccines and Treatment during the Public Health Emergency:
Code Short Descriptor Vaccine/Procedure Name Payment Allowance Effective Date Age limit
91300 SARSCOV2 VAC 30MCG/0.3ML IM Pfizer-Biontech Covid-19 Vaccine $0.01 12/11/2020 16 and older
0001A ADM SARSCOV2 30MCG/0.3ML 1ST Pfizer-Biontech Covid-19 Vaccine Administration – First Dose $16.94 12/11/2020 16 and older
0002A ADM SARSCOV2 30MCG/0.3ML 2ND Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose $28.39 12/11/2020 16 and older
91301 SARSCOV2 VAC 100MCG/0.5ML IM Moderna Covid-19 Vaccine $0.01 12/18/2020 18 and older
0011A ADM SARSCOV2 100MCG/0.5ML1ST Moderna Covid-19 Vaccine Administration – First Dose $16.94 12/18/2020 18 and older
0012A ADM SARSCOV2 100MCG/0.5ML2ND Moderna Covid-19 Vaccine Administration – Second Dose $28.39 12/18/2020 18 and older
Q0239 bamlanivimab-xxxx Injection, bamlanivimab, 700 mg $0.01 11/9/2020 N/ A
M0239 bamlanivimab-xxxx infusion Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring $309.60 11/9/2020 N/A

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Buckeye Health Plan covers, please contact Provider Services at 866.296.8731.

 

THE CENTERS FOR MEDICARE AND MEDICAID (CMS) RELEASE BILLING GUIDELINES FOR COVID-19 Vaccine

Allwell is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidelines for Medicare providers.  Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. However, please be aware the following billing specifics:

  • For Calendar Years (CYs) 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration for Medicare Advantage plan members will be made through the original fee-for-service Medicare program.
  • Allwell will not be able to process these claims.
  • Therefore, providers must submit claims for administering the COVID-19 vaccine to their CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved.

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive emergency use authorization (EUA) approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published as of NDecember 21, 2020. However, they will not be billable until the specific vaccine receives official EUA approval.

Payment Allowances and Effective Dates for COVID-19 Vaccines and Treatment during the Public Health Emergency:

Code Short Descriptor Vaccine/Procedure Name Payment Allowance Effective Date Age limit
91300 SARSCOV2 VAC 30MCG/0.3ML IM Pfizer-Biontech Covid-19 Vaccine $0.01 12/11/2020 16 and older
0001A ADM SARSCOV2 30MCG/0.3ML 1ST Pfizer-Biontech Covid-19 Vaccine Administration – First Dose $16.94 12/11/2020 16 and older
0002A ADM SARSCOV2 30MCG/0.3ML 2ND Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose $28.39 12/11/2020 16 and older
91301 SARSCOV2 VAC 100MCG/0.5ML IM Moderna Covid-19 Vaccine $0.01 12/18/2020 18 and older
0011A ADM SARSCOV2 100MCG/0.5ML1ST Moderna Covid-19 Vaccine Administration – First Dose $16.94 12/18/2020 18 and older
0012A ADM SARSCOV2 100MCG/0.5ML2ND Moderna Covid-19 Vaccine Administration – Second Dose $28.39 12/18/2020 18 and older
Q0239 bamlanivimab-xxxx Injection, bamlanivimab, 700 mg $0.01 11/9/2020 N/ A
M0239 bamlanivimab-xxxx infusion Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring $309.60 11/9/2020 N/A

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Allwell covers, please contact Provider Services at 866.296.8731.

THE CENTERS FOR MEDICARE AND MEDICAID (CMS) RELEASE AN Interim Final Rule Addressing COVID-19 Vaccine Coverage

Ambetter from Buckeye Health Plan is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have begun to publish guidance for providers.  Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients. In addition:

  • Ambetter from Buckeye Health Plan will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration
  • Member liability will be $0
  • Non-participating provider pre-auth requirements will be waived
  • Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

The following codes have been published as of December 21, 2020. However, they will not be billable until the specific vaccine receives official EUA approval.

Payment Allowances and Effective Dates for COVID-19 Vaccines and Treatment during the Public Health Emergency:

Code Short Descriptor Vaccine/Procedure Name Payment Allowance Effective Date Age limit
91300 SARSCOV2 VAC 30MCG/0.3ML IM Pfizer-Biontech Covid-19 Vaccine $0.01 12/11/2020 16 and older
0001A ADM SARSCOV2 30MCG/0.3ML 1ST Pfizer-Biontech Covid-19 Vaccine Administration – First Dose $16.94 12/11/2020 16 and older
0002A ADM SARSCOV2 30MCG/0.3ML 2ND Pfizer-Biontech Covid-19 Vaccine Administration – Second Dose $28.39 12/11/2020 16 and older
91301 SARSCOV2 VAC 100MCG/0.5ML IM Moderna Covid-19 Vaccine $0.01 12/18/2020 18 and older
0011A ADM SARSCOV2 100MCG/0.5ML1ST Moderna Covid-19 Vaccine Administration – First Dose $16.94 12/18/2020 18 and older
0012A ADM SARSCOV2 100MCG/0.5ML2ND Moderna Covid-19 Vaccine Administration – Second Dose $28.39 12/18/2020 18 and older
Q0239 bamlanivimab-xxxx Injection, bamlanivimab, 700 mg $0.01 11/9/2020 N/ A
M0239 bamlanivimab-xxxx infusion Intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring $309.60 11/9/2020 N/A

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Ambetter from Buckeye Health Plan covers, please contact Provider Services at 877.687.1189.

TALKING TO YOUR PATIENTS ABOUT The COVID-19 VACCINE: How you can engage and inform in a meaningful way

As COVID-19 vaccines are approved and distributed, providers will be a key part in its adoption and administration to the American public. Patients look to their healthcare professionals for medical guidance and assurance, and while much is still unknown, you can start laying the groundwork now for when the vaccines are available. As your partners in healthcare, we want to share some tips for effectively setting expectations and addressing questions from your patients.

Start COVID-19 Vaccine Conversations Early

Even before you are able to offer COVID-19 vaccinations, consider including the topic in your conversations with patients. This will give you the opportunity to set expectations about vaccine availability, including if/when you might recommend vaccination for them, and learn about any concerns they have.

Engage in Effective COVID-19 Vaccine Conversations

Effective engagement can occur during an in-person office visit, through messages on your patient portal, or at a telemedicine appointment. Patients trust in their providers to help guide healthcare decisions, and your strong vaccine recommendation is the most important part of the conversation.

Start with empathy and understanding.

  • Acknowledge the disruption COVID-19 has caused in all our lives.
  • Provide an opportunity to recognize common concerns that can be addressed by a vaccine.

Assume patients will want to be vaccinated but may not know when to expect it.

  • Consider providing the following general information to patients about the timeline for COVID-19 vaccines:
  • Limited COVID-19 vaccine doses may be available in 2020.
  • It is anticipated that vaccine supply will increase substantially in 2021.
  • The goal is for everyone to be able to easily get a COVID-19 vaccine as soon as large quantities are available. However, not everyone will be able to get vaccinated right away.
  • Encourage patients to continue taking steps to protect themselves from COVID-19 and let them know how you plan to share updates about vaccine availability.

Give your strong recommendation.

  • Let your patients know if you plan to recommend COVID-19 vaccination for them.
  • Share the importance of COVID-19 vaccines to protect patients’ health as well as the health of those around them.
  • Talk about your personal plans to get a COVID-19 vaccine.
  • Reassure your patients that the vaccine is safe.

Listen to and respond to questions.

  • If a patient has concerns or questions, this doesn’t mean they won’t accept a COVID-19 vaccine. Sometimes patients want your answers to their questions.
  • Your willingness to listen to their concerns will play a major role in building trust in you and your recommendation. Make it clear that you understand they have questions, and that you want to answer them, so they feel confident in choosing to get vaccinated.
  • Seek to understand patient/caregiver concerns and provide information they need in a way they can understand it (see Q&A below).

Keep the conversation open.

  • After answering their questions, let your patients know that you are open to continuing the conversation and answering any additional questions they may have.
  • Encourage patients to take at least one action like:
  • Scheduling another appointment.
  • Reading any additional information you provide them about COVID-19 vaccination.
  • Encourage others to get their COVID-19 vaccine when available.
  • Continue to remind patients about the importance of getting a COVID-19 vaccine during future routine visits.

Answering Patient Questions about the Vaccine

Your patients will likely have a lot of questions about the vaccine, and as their healthcare provider, they will turn to you for answers.

Q: Can I make an appointment with you to be vaccinated? If not, why? Do I have to go to a pharmacy to receive the vaccine?

A: Pharmacies are generally the most convenient locations to individuals and they also have great expertise in administering vaccines. While many providers anticipate to have the vaccine in their office later on, for now we recommend patients visit their local pharmacy. The website www.vaccinefinder.org  can help them locate the closest location with current inventory.

Q: Why are some people getting the vaccine before others? Why can’t I get mine yet?

A: Initially, there will be a limited number of vaccines available.  Because of the limited supply, some groups are recommended to get the vaccine first:

  • Phase 1A will include residents and employees of nursing homes and long-term care facilities.  They are recommended to get the vaccine first, as they are deemed highly vulnerable.  Long-term care facilities account for a high percentage of the deaths from COVID-19 (40%).
  • Additional phases are being developed by federal and state governments.  This will address first-responders, essential workers, older adults and people more at risk for either contracting the virus or becoming seriously ill with the virus.

Q: How do we really know if COVID-19 vaccines are safe? 

A: The Food and Drug Administration (FDA) carefully reviews all safety data from clinical trials. It only authorizes emergency vaccine use when the expected vaccine benefits outweigh potential risks.

  • The Advisory Committee on Immunization Practices (ACIP) reviews all safety data before recommending any COVID-19 vaccine for use.
  • FDA and CDC will continue to monitor the safety of COVID-19 vaccines to make sure even very rare side effects are identified.

Q: Is the vaccine that helpful? I heard getting COVID-19 gives you better and longer immunity than the protection a vaccine can give. Can it actually make my illness worse if I do end up getting COVID-19? 

A: Explain the potential serious risk COVID-19 infection poses to them and their loved ones if they get the illness or spread it to others.

  • Remind them of the potential for long-term health issues after recovery from COVID-19 disease, especially for those who have chronic conditions, are older, or have weakened immune systems.
  • Explain that scientists are still learning more about the virus that causes COVID-19. And it is not known whether getting COVID-19 disease will protect everyone against getting it again, or, if it does, how long that protection might last. Therefore getting a vaccine is a safer choice.
  • Some vaccines are more effective than the natural illness; it is not clear whether natural illness or vaccination will provide more effective immunity in this case.
  • Early information indicates that COVID-19 vaccination may reduce the severity of illness, as well as the incidence of illness. As we learn more about the efficacy of the vaccine, we will also learn more about potential long-term protection it may bring.
  • Describe how the vaccine was tested in large clinical trials and what is currently known about its safety and effectiveness.
  • Be transparent that the vaccine is not a perfect fix. Patients will still need to practice other precautions like wearing a mask, social distancing, handwashing and other hygiene measures until public health officials say otherwise.

Q: I heard I need 2 vaccines. Why? I don’t want to come back for a second vaccine.

A: Two vaccines are needed to provide the best protection against COVID-19.

  • The first vaccine primes the immune system and helps recognize the virus. The second vaccine strengthens the immune response.
  • The two doses are given a few weeks apart (e.g. 21 or 28 days depending on vaccine type). Explain the dosing options available in your office and advise the patient that they can set up an appointment before they leave to come back for a second dose.
  • Provide members with a vaccination record card to ensure that they know when they received their first vaccine, what type of vaccine they received, and when they need to come back and receive their second vaccine.
  • Direct them to their insurance health plan to set up non-emergency transportation, if applicable.

Q: Will the shot hurt? Can it cause you to get sick? I don’t want to get the vaccine because it will give me COVID.

A: List the most common side effects from vaccination are and how severe they may be (e.g. fever, headache, body aches, cold symptoms). Emphasize that a fever could be a potential side effect and when to seek medical care.

  • Symptoms will typically go away on their own within a week. Let them know when they should seek medical care if their symptoms don’t go away.
  • Explain that the vaccine cannot give someone COVID-19 as the vaccine does not contain a live coronavirus.
  • Explain that side effects are a sign that the immune system is effectively working.

Q: Do I have to pay for my vaccines?

A: No! The vaccine will be at no cost to patients. They will not have to pay for either dose of the COVID-19 vaccine.

Follow Vaccine Updates from Trusted Sources of Truth

The Centers for Disease Control (CDC)

National Institutes of Health (NIH)

The Centers for Medicare and Medicaid (CMS)

The American Medical Association (AMA)

Section One: Post- Acute Care Prior Authorization Changes

Updated 11-18-20 for Buckeye Medicaid, MyCare, Medicare and Ambetter members.

To reduce barriers to care and reduce administrative burden for providers caring for our Buckeye Medicaid, MyCare, Medicare and Ambetter members, we have made the following changes to our prior authorization policies:

  1. Prior authorization requirements for long term acute care facilities (LTAC), skilled nursing facilities (SNF) and inpatient rehabilitation facilities (IRF hospital) are being waived.  Upon admission to your facility, please contact Buckeye Health Plan as you do today to allow for determination of appropriate level of care and to continue concurrent stay review to assist with discharge planning activities to ensure safe transitions to next the level of care including:
    • Ensuring member are transferred to appropriate level of care
    • Adding services for member home care needs
    • Expediting referrals to participating providers
    • Ensuring all plans are in place before the member discharge

      NOTE:  Non-Par facilities: please accept 100% of Medicaid Fee Schedule and No Single Case Agreement will be required.
       
  2. We will extend authorizations for elective hospital services and surgical procedures for up to six months when treatments, procedures or services have been postponed.

Contact by phone:  866-246-4359

Fax: SN/Rehab/LTAC requests 866-529-0291 / Elective and /or scheduled admits 866-529-0290

Section Two: Inpatient Hospital Prior Authorization Changes

Dates of Service 11-30-20 through 12-31-20 for Buckeye Medicaid, MyCare, Medicare and Ambetter members:

  1. Authorizations for Behavioral Health admissions and Medical/Physical Health admissions will be waived for dates of service 11-30-20 through 12-31-20. 
  2. You may continue to notify Buckeye Health Plan as you do today of admissions to have authorizations processed. 
  3. We will extend authorizations for elective hospital services and surgical procedures for up to six months when treatments, procedures or services have been postponed.

Section Three:  Outpatient Services and Procedures Prior Authorization Changes

Dates of Service 11-30-20 through 12-31-20 for Buckeye Medicaid and Ambetter members:

1. Authorizations will be waived for the services and procedures below:

  • BH/PH Home Health  services (SN, PT, OT, ST)–  first 6 visits
  • OP Therapy (PT, OT, ST) per modality per member – first 12 visits
  • Cardiac Rehab
  • Pulmonary Rehab
  • Respiratory equipment – first 3 months
    • Oxygen
    • CPap
    • BiPap
    • Vents
    • Home Pulse Oximeter
  • Infusion Pumps (excluding insulin and pain pumps)
  • DME
  • Home IV Antibiotics
  • Enteral Nutrition
  • Total Parenteral Nutrition

2. Prior authorization will be required for all other services, including but not limited to:

  • BH/PH Home health services (SN, PT, OT, ST) after the 6th visit
  • Outpatient therapy (PT, OT, ST)  per modality per member after 12th visit  (notification of 1st visit required)
  • Respiratory equipment after 3 months
    • Oxygen
    • CPAPs
    • BiPaps
    • Vents
  • Infusion Pumps
  • All elective surgical and dental procedures
  • All Transplants
  • Cosmetic procedures
  • The use of all miscellaneous codes such as E1399
  • Pain Management services to include Pain Pumps
  • All custom and/or powered equipment to include prosthetics and orthotics

Contact Information:

Contact by phone:  866-296-8731

 

On October 5, 2020, HHS Secretary Alex Azar renewed the COVID-19 Public Health Emergency. This extends flexibilities and funding tied to the public health emergency (PHE) to continue through January 21, 2021.

With this renewal the various testing, screening, billing, and telehealth coverages that were implemented in response to the COVID-19 Public Health Emergency earlier this year will be extended to Buckeye Health Plan members through late January, until the PHE is either terminated or extended again.  This extension does not affect coverages that had already been made effective through December 31, 2020.

In accordance with this extension, Buckeye Health Plan has updated the General Guidance for COVID-19 Testing, Screening, and Treatment document, as well as the COVID-19 Telehealth Guidance for Providers documents posted on our website.

If you have any questions about this extension or the covered benefits impacted by it, please contact Provider Services at 866-296-8731.

In order to ensure that all of our members have needed access to care, we are increasing the scope and scale of our use of telehealth services for all products for the duration of the COVID-19 emergency.  These coverage expansions will benefit not only members who have contracted or been exposed to the novel coronavirus, but also those members who need to seek care unrelated to COVID-19 and wish to avoid clinical settings and other public spaces.

Effective immediately, the policies we are implementing include:

  • Continuation of zero member liability (copays, cost sharing, etc.) for care delivered via telehealth*
  • Any services that can be delivered virtually will be eligible for telehealth coverage
  • All prior authorization requirements for telehealth services will be lifted indefinitely for dates of service beginning March 9, 2020 
  • Telehealth services may be delivered by providers with any connection technology to ensure patient access to care**

*Please note: For Health Savings Account (HSA)-Qualified plans, IRS guidance is pending as to deductible application requirements for telehealth/telemedicine related services. 
**Providers should follow state and federal guidelines regarding performance of telehealth services including permitted modalities.

Providers who have delivered care via telehealth should reflect it on their claim form by following standard telehealth billing protocols in their state.

We believe that these measures will help our members maintain access to quality, affordable healthcare while maintaining the CDC’s recommended distance from public spaces and groups of people. 

Please refer to ODM's website for the full Telehealth Billing Guidelines During COVID-19 State of Emergency (PDF). This document was updated on July 17, 2020

Buckeye Health Plan is working to quickly address and support screening, testing and treatment for COVID-19, and is closely following guidance from the Centers for Medicare and Medicaid Services (CMS). As of April 1, 2020, the following guidance can be used to bill for services related to the screening and treatment of COVID-19.

COVID-19 Screening Services

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived for COVID-19 screening visits and if billed alongside a COVID-19 testing code.
  • This applies to services that occurred as of February 4, 2020.

As a reminder, only those services associated with screening and/or treatment for COVID-19 will be eligible for prior authorization and member liability waivers.  For screening or treatment not related to COVID-19 normal copayment, coinsurance, and deductibles will apply.

CMS has new COVID-19 ICD-10 procedure codes that will be effective date on 8/1/2020. Please refer to the ICD-10 MS-DRGs Version 37.2 (PDF).

We are closely monitoring and following all guidance from the Centers for Medicare and Medicaid (CMS) as it is released to ensure we can quickly address and support the prevention, screening, and treatment of COVID-19. Coding and modifier information for the expansion of telehealth benefits are available in the ODM Billing Guidance document. Access to this and other key documents around COVID-19 can be found on ODM's website.    

In addition, below is specific Buckeye Health Plan guidance.

COVID-19 Testing Services

  • All member cost share (copayment, coinsurance and/or deductible amounts) will be waived across all products for any claim billed with the new COVID-19 testing codes.
  • We have configured our systems to apply $0 member cost share liability for those claims submitted utilizing these new COVID-19 testing codes.
  • In addition to cost share, authorization requirements will be waived for any claim that is received with these specified codes.  
  • Providers billing with these codes will not be limited by provider type and can be both participating and non-participating.
  • We will temporarily waive requirements that out-of-state Medicare and Medicaid providers be licensed in the state where they are providing services when they are licensed in another state.
  • Adjudication of claims is currently planned for the first week of April 2020.

Medicare Reimbursement Rates for COVID-19 Testing Services for All Provider Types*

We are complying with the rates published on 3/12/20 by CMS:

  • U0001 = $35.91
  • U0002 = $51.31

Please note: Commercial products will reimburse COVID-19 testing services in accordance with our negotiated commercial contract rates.

Any additional rates will be determined by further CMS and/or state-specific guidance and communicated when available.

Buckeye Health Plan can assist FQHC providers with receiving PPE (mask, gloves, gowns, hand sanitizer).

Tara Bires - TBires@centene.com is the facilitator of these request and can assist you with getting supplies to the FQHCs.

To assist our providers in accessing the multiple funding streams available, the Business Development team is developing a page on the Centene website that will:

  • Provide access  to the SBA loan application
  • Help providers understand available funding opportunities (SBA and grant funding)
  • Connect them with a member of the Business Development team that can assist in completing required applications.

You will find more details around the CARES Act (financial assistance and relief) and the EIDL and PPP loans available on our Centene site.

Buckeye’s Pharmacy team is working to increase member access to medications where appropriate for COVID-19.

  1. Increase member access to medications where appropriate for COVID-19:
    • Refill too soon over rides
    • Quality limit over rides
    • Prior authorization over rides
    • Exception: Refill too soon override NOT allowed for opioids.
  2. Over-the-counter (OTC) medications may be covered through the Medicaid pharmacy benefit without a prescription.
  3. 90-day supply for medications along with HIV and Transplant medications
  4. Delivery of medications with no additional charge to member. Below is a list of some of the major chains that participate in this effort:
    • CVS
    • Walgreens
    • Exactcare Pharmacy

The Centers for Medicare & Medicaid Services (CMS) have released guidance for implementing several provisions included in the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Buckeye Health Plan will be following this guidance as we adjudicate Medicare claims for applicable COVID-19 inpatient treatment services.

The CARES Act provides for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. The increase will be applied to claims that include the applicable COVID-19 ICD-10-CM diagnosis code and meet the date of service requirements, as follows:

For discharges with the diagnosis codes above, [HEALTH PLAN] will follow the Medicare billing guidance published by CMS (PDF). Inpatient claims for these COVID-19 discharges that have already been received will be automatically reprocessed to reflect the payment increase.

This guidance is in response to the COVID-19 pandemic and may be retired at a future date.

Sources:

The Centers for Medicare and Medicaid (CMS)

The Centers for Disease Control (CDC)

Allwell from Buckeye Health Plan EXTENDS $0 MEMBER LIABILITY FOR Primary Care, Behavioral Health, and Telehealth SERVICES for Remainder of 2020

Since March, Allwell from Buckeye Health Plan has waived pre-authorizations, co-pays, and other costs related to COVID-19 testing, screening and medically necessary treatment. We also have waived prescription refill limits, and members are able to refill prescriptions prior to their refill date during this crisis.

As seniors face increased social and economic barriers to care amid the pandemic, we are now offering a number of expanded benefits to help our eligible Medicare Advantage members address issues such as out-of-pocket medical costs, food insecurity, and medication assistance.

Effective July 1, 2020, expanded benefits will include:

  • $0 Member Liability Extension: We are waiving in-network member costs for all primary care visits for the rest of 2020. We are also waiving member costs for outpatient, non-facility-based behavioral health visits and are extending telehealth cost share waivers for all telehealth visits—primary care, specialty, and behavioral health—for in-network providers for the remainder of 2020. This does not include inpatient hospital, behavioral health facility, or urgent care visits. Medicare members with state benefits will continue to receive support through coordination with their states.
  • Extended Meal Benefits Members eligible for meal benefits due to a chronic condition or recent discharge may receive an additional 14 meals delivered to their home at no cost.
  • Increased Annual Wellness Visit Incentives – Members may be eligible for an increased incentive for completing their Annual Wellness Visits, a benefit offered at no cost to the member.
  • Additional Over-The-Counter (OTC) Benefits – Plans with an OTC benefit may now receive additional allowance dollars in monthly or quarterly increments, adding up to as much as $150 for the remainder of 2020, depending on plan.
  • Access to WellCare’s Community Connections Help Line – The Community Connections Help Line – a toll-free line provided by our partners at WellCare and available to anyone in need – is staffed by peer coaches and support specialists who can refer individuals and caregivers in need to a database of more than half a million social services in local communities across the country. By calling the line at 1-866-775-2192, members can also receive help coordinating of the expanded meal program benefits, OTC allowances, and annual wellness visit incentives via the line.

Beginning July 1, 2020, providers should waive the member liability for the eligible primary and behavioral health care claims at the point of service, and forego the collection of the member cost share. This is a benefit change for our members and our claims system will be configured to administer these adjusted benefits. We recognize that providers have different reimbursement/accounting arrangements with us, and the costs associated with this benefit change will follow the accounting processes as outlined in the provider’s contract with Allwell from Buckeye Health Plan. For services rendered to Medicare members with state benefits, providers should continue to collect that member cost share from their State Medicaid Agency as per usual.

The COVID-19 global pandemic has created unprecedented changes to our lives and healthcare systems. While we continue to connect our members to COVID-19 services, we wanted to reach out to our provider partners on how we can work together to better support their care needs.

As a primary care physician (PCP), you are at the heart of our members’ healthcare. They trust and rely on you to help them access appropriate, affordable, coordinated care from the right providers, at the right time. If you refer our members to an out-of-network provider – or send their test specimens to a non-participating laboratory – they could be responsible for the out-of-network charges according to their benefits. These costs can quickly add up, especially for patients who do not have out-of-network benefits.

You can help your patients avoid this and keep their medical costs down by referring them to providers within their Buckeye Health Plan network, as denoted on their Member ID card. Understanding it can sometimes be challenging to navigate multiple payor networks to connect patients to appropriate in-network providers and facilities, we want to share two easy methods for you to access this information quickly:

Thank you for your continued partnership during this time of heightened concern. If you have any questions regarding our networks, please contact Provider Services at 1-866-296-8731.

This guidance is in response to the current COVID-19 pandemic and may be retired at a future date.

There are many additional resources for information around COVID-19, coding for expanded telehealth services and other Ohio-specific information from the Ohio Department of Medicaid:

ODM links

OAC rules for OhioMHAS and ODM

CMS (Medicare) links

CMS Telehealth Guidelines for Medicare

September 2020 Update: Retrospective Reviews have been postponed until further notice by the Ohio Department of Medicaid (ODM) to ensure that barriers are removed for providers that care for our members. 

Buckeye Health Plan is currently analyzing claims that paid without authorization during the time that the Ohio Department of Medicaid Emergency Amendment “S” was in effect (March 9- June 30, 2020). 

Beginning July 1, 2020, BHP will perform retrospective medical necessity reviews of claims paid without authorization from March 9-June 30, 2020, following this schedule:
 

Dates Steps
July 1-31, 2020
  1. Identify inpatient claims paid without authorization and share with respective providers.

August 1-31, 2020

  1. Requests for medical records of identified inpatient claims.
  2. Identify outpatient claims paid without authorization and share with respective providers.

September 1 – November 1, 2020  

  1. Requests for medical records of identified outpatient claims.
  2. BHP review of identified inpatient claims and recoupment requests, as required.

November 1, 2020 – June 2021

  1. BHP review of identified outpatient claims and recoupment requests, as required.