Navigating HHS’ COVID-19 Testing and Treatment for the Uninsured Program: The 5 Basics that Providers Should Know

Five Critical Things Providers Should Know Regarding HHS’ COVID-19 Testing and Treatment for the Uninsured Program

Although it has been more than a year since HHS declared a public health emergency, providers are still struggling to navigate the extensive and changing legislation and regulations enacted to help healthcare entities respond to the coronavirus pandemic. For programs like the Provider Relief Fund, HHS has continuously updated and clarified its guidance to address recent legislation and questions submitted by providers. However, the guidance issued for the COVID-19 Claims Reimbursement for Testing, Treating, and Vaccine Administration of the Uninsured Program (Program) and other programs are less clear. Many providers are hesitant to participate in this optional Program, due to a lack of understanding of its basic terms and definitions.

This Program, administered by the Health Resources & Services Administration (HRSA), reimburses healthcare providers for testing uninsured individuals for COVID-19, treating uninsured individuals for COVID-19 diagnoses, and vaccinating uninsured populations. Reimbursement is funded by the Families First Coronavirus Response Act (FFCRA), the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA), the Coronavirus Aid, Relief, and Economic Security Act (CARES), and the Coronavirus Response and Relief Supplemental Appropriations Act (CRRSA).

The Congressional Budget Office (CBO) estimated that the number of uninsured individuals in the U.S. increased to 31 million in 2020. As the pandemic enters its second year, providers should understand their options for federal reimbursement. These options can benefit both the patient and provider, easing the burden on those impacted most by the coronavirus. Providers considering Program participation, as well as those currently participating in this Program, should have a clear understanding of the following five key points prior to enrolling and/or submitting claims for reimbursement:

1. Provider Eligibility
As defined by HRSA, “[h]ealth care providers who have conducted COVID-19 testing or provided treatment for uninsured individuals with a COVID-19 primary diagnosis on or after February 4, 2020 or provided COVID-19 vaccine administration to uninsured individuals can electronically request claims reimbursement through the program and will be reimbursed generally at Medicare rates, subject to available funding.” Healthcare providers is broadly defined, including Health Centers, pharmacies, and all eligible providers who test, treat, or vaccinate uninsured individuals. Any provider who is on the Medicare Exclusion List and/or any provider who has had their Medicare enrollment revoked by CMS is ineligible for this Program.

To participate, healthcare providers must enroll via HRSA’s online portal as a provider participant and attest to the following:
• You have checked for healthcare coverage eligibility and confirmed that the patient is uninsured. You have verified that the patient does not have coverage through an individual, or employer-sponsored plan, a federal healthcare program, or the Federal Employees Health Benefits Program at the time services were rendered, and no other payer will reimburse you for COVID-19 vaccination, testing and/or care for that patient.

• You will accept defined program reimbursement as payment in full.
• You agree not to balance bill the patient.
• You agree to program terms and conditions and may be subject to post-reimbursement audit review.

Once enrolled, providers will use the portal to verify patient eligibility and information, submit claims, and receive payment information.

2. “Uninsured” Individuals
Under the Program, providers may submit claims for individuals in the U.S. who are uninsured. For testing purposes, the FFCRA defines “uninsured” as an individual who is not enrolled in a federal healthcare program or specified types of private health insurance coverage. For treatment and vaccination purposes, the definition of “uninsured” is less specific. A patient is considered uninsured if the patient did not have any healthcare coverage at the time the services were rendered. The Program will reimburse providers regardless of the patient’s citizenship status. Prior to submitting claims for reimbursement, providers must verify and attest that to the best of the provider’s knowledge at the time of claim submission, the patient was uninsured at the time the services were rendered. If the provider learns that the individual is retroactively enrolled in Medicaid as of the date of service, the provider must return the reimbursement to HRSA.

There is an important distinction in the definition of “uninsured” among the various programs. FFCRA, as amended by the CARES Act, permits states to use Medicaid to pay eligible providers for COVID-19 testing to uninsured individuals throughout the public health emergency. Notably, the definition of “uninsured” includes additional groups, including certain Medicaid enrollees with limited coverage. However, unlike the HRSA administered Program, eligible uninsured individuals must meet Medicaid eligibility requirements, such as federal and state requirements for immigration status and documentation of U.S. citizenship, to enroll in this option. In addition to 18 other states, Louisiana Medicaid has expanded coverage to include COVID-19 testing and testing related services under this option. Additionally, it has increased benefits and eliminated copays for Medicaid beneficiaries for COVID-19 treatment and vaccinations.

3. Covered Services
Providers may submit claims for qualifying testing for COVID-19, for treatment services with a primary COVID-19 diagnosis, and for qualifying COVID-19 vaccine administration fees.

HRSA has published the following examples of covered services:

• Specimen collection, diagnostic and antibody testing.
• Testing-related visits including in the following settings: office, urgent care or emergency room or telehealth. Notably, not hospitals.
• Treatment: office visit (including telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), rehabilitation care, home health, durable medical equipment (e.g., oxygen, ventilator), emergency ambulance transportation, non-emergent patient transfers via ambulance, and FDA-licensed, authorized, or approved treatments as they become available for COVID-19 treatment.
• Administration fees related to FDA-licensed or authorized vaccines.

Despite broad coverage for COVID-19 tests, treatment, and vaccination, there are important limitations.

• Testing: Providers are eligible to receive reimbursement for COVID-19 testing and testing-related services of uninsured individuals, regardless of the test results or reason for testing. For example, if a provider tests for COVID-19 as part of pre-operative or other medical treatment unrelated to COVID-19, the test may be reimbursed under the Program. To be eligible for reimbursement, claims for diagnostic testing and testing related services must include one of the diagnostic codes enumerated in HRSA’s FAQs.
• Vaccination: Providers are eligible to receive reimbursement for vaccinating uninsured individuals. Importantly, the government currently supplies FDA-authorized COVID-19 vaccine doses to providers, so only the cost of vaccine administration will be reimbursed through this Program. As vaccines become more widely available, HRSA will likely issue additional guidance.
• Treatment: The “primary diagnosis” requirement has proven to be an unanticipated limitation for providers treating COVID-19 patients. For treatment to be eligible for reimbursement, COVID-19 must be the uninsured individual’s primary diagnosis on the claim. In some cases, patients with COVID-19 may be treated for COVID-19 related-symptoms without a COVID-19 primary diagnosis. The American Hospital Association (AHA) found that this is an issue for providers treating patients with sepsis caused by COVID-19. Providers are required to code these patients with sepsis as their primary diagnosis since that is the active issue. However, without a primary COVID-19 diagnosis, services provided to the uninsured individual are ineligible for reimbursement. Moreover, if a patient is admitted to the hospital and he or she receives a negative COVID-19 test, the testing-related services would be ineligible for reimbursement. This is because hospitals are not one of the listed eligible care settings for testing (i.e., office visit, telehealth visit, emergency room, etc.). The negative test result would make the treatment also ineligible for reimbursement since COVID-19 must be the primary diagnosis for admission.

Additionally, the Program expressly excludes reimbursement for the following services:

•  Any treatment without a COVID-19 primary diagnosis, except for pregnancy when the COVID-19 code may be listed as secondary.
• Hospice services.
• Outpatient prescription drugs.

Finally, uninsured individuals whose treatment costs were covered by a hospital charity program will not be eligible for Program reimbursement. Like the CARES Act Provider Relief Fund, the Program’s Terms and Conditions require providers to certify that they will not use the payment to reimburse expenses or losses that have been reimbursed from other sources.

4. Claim Filing Limits
Providers must submit claims through HRSA’s COVID-19 Uninsured Program Portal within 365 calendar days from the date of service or admittance.

5. Provider Reimbursement
Providers must submit all reimbursement claims electronically through HRSA’s COVID-19 Uninsured Program Portal. Generally, reimbursement rates are based on current year Medicare fee schedule rates, and most claims are reimbursed within 30 days of submission. Notably, if the provider received any payment from the patient, the provider must return these funds if the provider is reimbursed through this Program. Providers should treat Program funds in the same manner as reimbursement received through federal and private health plans for cost reporting purposes.

Program participants should consult with experienced legal counsel and carefully review HRSA’s guidance, including the Testing Terms and Conditions and Treatment Terms and Conditions for reimbursement, as well as HRSA’s FAQs.