Coronavirus (COVID-19) and HAP coverage updates for providers

• Vaccine policy
• Vaccine information for members

Does HAP waive cost sharing for COVID-19 testing and treatment?

Yes. Please see details below.

• Testing: HAP will waive member cost-sharing for COVID-19 diagnostic tests and test related visits, including virtual/telehealth visits, during the public health emergency according to state and federal guidelines. This cost- sharing waiver applies to testing from in-network or out-of-network providers. Member cost-sharing for all other diagnostic tests will continue to apply. Self-insured employer group customers control their own health benefits; employees of self-funded employer groups should confirm cost- sharing when seeking services.
• Antibody testing: HAP will waive member cost-sharing for the COVID-19 antibody test during the public health emergency if the test is FDA approved and is ordered by a qualified health professional according to CDC recommendations.
• Rapid testing: HAP will waive member cost-sharing for a rapid COVID-19 test during the public health emergency if the test is FDA approved and is ordered by a qualified health professional according to CDC recommendations.
• Home test kits: HAP will waive member cost-sharing for at-home COVID-19 diagnostic tests during the public health emergency if the test is FDA approved and is ordered by a qualified health professional who has determined that the test is medically appropriate for the individual according to CDC recommendations. The accuracy of at-home testing is still uncertain and these are not widely available.
• Treatment: HAP will waive member cost-sharing (which includes deductibles, copays and co-insurance) for treatment related to an acute diagnosis of COVID-19 infection. This cost-sharing waiver is for inpatient or outpatient treatment from an in-network provider and is currently in effect for services rendered through September 30, 2021. Beginning Oct. 1, 2021, coverage for the treatment of COVID-19 will return to the standard benefit. HAP does not waive cost sharing for treatment of ongoing complications stemming from a previous COVID-19 diagnosis.

Self-insured employer group customers control their own health benefits; employees of self-funded employer groups should confirm cost-sharing when seeking services.

Also, testing required by employers, such as tests necessary to allow employees to return to work, is not a covered benefit. The employer and/or member is responsible for the cost of these tests.

How does HAP define telehealth and virtual visits?

Telehealth is defined as real time audio/visual visit. Virtual visit is defined as a phone visit. with provider. CMS guidelines have changed due to COVID-19; therefore, if a provider can do any kind of HIPAA compliant video or audio call such as FaceTime or Skype, that is considered a telehealth visit.

How is HAP covering virtual visits and telehealth?

Cost-sharing is waived for HAP individual, fully-insured group, Medicare, Medicaid and MI Health Link members using telehealth services related to a COVID-19 diagnosis through September 30, 2021. 

Member cost share will apply for telehealth services that are not related to an acute diagnosis of COVID-19 infection. 

Eligible members who have an established relationship with a behavioral health provider can reach out directly to the provider’s office to confirm their telehealth capabilities. All members with questions related to behavioral health can call customer service or the mental health services number on the back of their HAP ID card.

Self-insured employer group customers control their own health benefits; employees of self-funded employer groups should confirm cost-sharing when seeking services.

Beginning Oct. 1, 2021, coverage for the treatment of COVID-19 will return to the standard benefit.

Are wellness services (G0438 and G0439) covered via telehealth?

Yes, wellness visits (G0438 and G0439) are covered when provided via telehealth. Please refer to our Benefit Administration Manual for the Telemedicine, Telehealth & Virtual Care Services policy. The policy also contains links to CMS resources for codes. 

Are preventive visits covered via telehealth? 

Preventive visits (99381-9939) are not covered via telehealth, consistent with CMS guidelines.  These service codes include expectations or aspects of care that are not feasible by audio/visual telemedicine technology (listening to breath sounds, heart sounds, palpitation of the abdomen, etc.). We’re reevaluating if this could be covered in the future.

Do you cover PT/OT/ST therapy via telehealth?

Yes. Please refer to our Benefit Administration Manual for the Telemedicine, Telehealth & Virtual Care Services policy for more information. Applies to all Medicare Advantage, HAP/AHL Commercial and Individual product members. HAP Empowered Medicaid members continue to follow MDHHS directives.

Do you cover autism via telehealth?

Yes. Please refer to our Benefit Administration Manual for the Autism Spectrum Disorders, Evaluation and Treatment policy for coverage criteria.

Is prior authorization required for skilled nursing facility admissions from an acute care facility? 

On January 21, 2022, we extended the temporary prior authorization waiver for skilled nursing facility admissions through March 6, 2022.

Effective March 7, 2022 prior authorization will be required for admission to or continued stay at:

• Skilled nursing facilities (SNF)
• Inpatient rehab facilities (IRF)
• Long-term acute care at hospitals (LTACH)

Please follow the process below.

Process for HAP Medicare Advantage members

• Contracted hospitals and skilled nursing facilities submit prior authorization requests to naviHealth via:
  • Online via nHAccess on naviHealth’s portal
  • Fax at (888) 927-0718

For resources, visit naviHealth's resource page.

Process for other HAP members and HAP Empowered members

We have facilities designated as a Highly Preferred Skilled Nursing Facility for HAP.

Highly Preferred SNFs

• Do not submit prior authorization requests when admitting these members.
• Within 3 business days of the admission date, submit the following information:
  • Patient medical history and physical
  • Therapy evaluation
  • Proof of medical necessity (only if therapy isn’t required)
  • Face sheet

You can fax it to (313) 664-5820. All members will undergo a clinical review within seven to 10 days of admission. 

Skilled nursing facilities without the highly preferred designation, IRF and LTAC

• Submit prior authorization requests via fax at (313) 664-5820 or Allscripts

Have effective dates of existing and new pre-service authorizations been extended?

Yes. We’ve extended effective dates of existing and new pre-service authorizations to 365 days; 180 days now for high-tech imaging, sleep studies and ZOLL LifeVests.

Has HAP removed authorizations for out of plan/out of network services for any members? 

Yes. We’ve removed authorizations for out of plan/out of network services for all Medicare, MMP and DSNP. No PCP referrals required for HAP Primary Choice Medicare (HMO) and HAP Choice Medicare (HMO) plans. 

Has HAP removed referral requirements for any plans requiring them?

Yes. Referrals are not required for HAP Primary Choice Medicare (HMO) plans, HAP Choice Medicare (HMO) plans, tiered network plans. This is effective March 10 through end of the PHE.  

Will HAP waive authorization for outpatient testing with a suspected or confirmed COVID diagnosis, i.e. high-tech imaging, DME?

Yes.

Does HAP temporarily allow speech therapy for children with a diagnosis other than autism at medical facilities since services are not available at schools now due to state of emergency?

Yes. However, effective July 15, 2021, requests for speech therapy at medical facilities will not be approved for children 18 or younger with a diagnosis other than:

• Autism
• Acute illness
• Medical indication such as surgery

These members will be directed to their school district for speech therapy services.

Do you cover out of network care for COVID-19 for Medicare members? 

Yes. We cover all medically necessary covered Medicare Advantage plan benefits provided at non-contracted providers. The provider must participate with original Medicare. This is effective March 10 through end of State declared emergency

What is HAP doing to offer financial relief for providers?

We pay claims quickly and have experienced no operational barriers to our work. Additionally, we’re providing cash flow relief by expediting our 2019 Best Practice payments. We’re evaluating other opportunities for financial relief.

What other financial relief are you offering HAP members?

Monthly premium changes for individual members and small group customers
HAP will decrease monthly premiums by 5 percent through the end of the year. These decreases will be reflected in monthly premium bills beginning July 1 and will be in effect through December 2020.

How is HAP handling sequestration?

HAP will follow the Centers for Medicare and Medicaid Services and restrict sequestration temporarily beginning May 1, 2020. Per CMS, section 3709 of the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”), temporarily suspends sequestration of Medicare programs between May 1, 2020 and December 31, 2020, which we will refer to as the “sequestration suspension period.”

What is HAP doing for prescriptions?

HAP is offering free in-home medication delivery service to ensure our members have adequate drug supply on hand. The delivery cost is free for members to get medications sent to their homes through Pharmacy Advantage. HAP members can request all their drugs from Pharmacy Advantage. This service is available for all of our HAP members - Medicare, Medicaid, Dual Medicare/Medicaid, and Commercial population.

What if members can’t get prescriptions from in network pharmacies?

HAP will reimburse members for prescriptions obtained from out of network pharmacies when the member cannot reasonably obtain medications from in network pharmacies

What prior authorization requirements are you following during this time?

HAP will follow the MDHHS and CMS guidance below.

What documentation can be used for hospital discharges that require oxygen treatment?

DME suppliers can use provider’s documentation of COVID-19 rationale for O2 equipment with a qualifying oxygen sat. DME script can be written for up to 60 days if medically necessary from date of discharge. Discretion of provider to determine allowable timeframe. After prescription expires, the patient will require a reevaluation.

With an increase in oxygen orders with the primary diagnosis of COVID-19, is the diagnosis COVID-19 enough on its own? If sufficient, how long can oxygen be provided to patients with the primary (only) diagnosis of COVID-19? 

COVID-19 diagnosis with a qualifying oxygen sat. qualifies for up to first 60 days or length of script and then patient needs to be re-evaluated. DME supplier should check at 30 days to assess if patient requires oxygen beyond the initial 30 days or when patient no longer needs oxygen any longer. Use new diagnosis code U07.1, COVID-19, effective from April 1, 2020. Use CDC codes for COVID-19 conditions before the new COVID-19 code is available.

With members fearing they will run out of supplies; can we ship orders early?

HAP will follow CMS billing rules for refills which allows to process well in advance. This will minimize unintended consequence of DME shortages due to stockpiling. DME can be delivered as early as 10 calendar days earlier than refill date which HAP follows for Medicare, Medicaid and Commercial.

Will HAP offer subsidy’s to members or suppliers who have out-of-pocket expenses for DME/medical supplies, if the member can’t make payments due to COVID-19 impacts?

HAP will follow CMS and MDHHS guidelines for member cost share which at this time does not include the scope of DME and supplies. HAP will continue to assess the environment for additional changes.

Will HAP waive requirements on the prescription (date of birth, ID number, diagnosis, gender, times testing, etc.)?

HAP will follow MDHHS and CMS guidance below.

Will HAP waive medical record documentation, if required for a supply or order if we’re unable to obtain it during this time?

HAP will follow MDHHS and CMS guidance below.

Will HAP waive expired documentation or prescription renewals for existing members?

HAP will follow MDHHS and CMS guidance below.

MDHHS Guidance
Bulletin MSA 20-14: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Providers, Hospitals, Physicians, Pharmacies, Medicaid Health Plans (MHPs), Integrated Care Organizations (ICOs)
Start Date: March 26, 2020 
End Date:  30 days following the termination of the Governor’s Declaration of a State Emergency Order (2020-04, COVID-19) or the first of the following month, whichever is later
Applies to: MMP, Medicaid, HMP, CSHCS
Excludes: Commercial and Medicare

Here are the guidelines from the MDHHS:

• Waive quantity limits, prior authorization and documentation requirements for: 
  • Respiratory equipment/supplies (e.g. ventilators, suction catheters, oxygen, etc)
  • Medical supplies the member typically receives through home delivery (e.g. diabetic supplies, incontinence supplies, enteral formulas, etc.)
• Ordering provider must establish medical necessity for specified equipment/supplies and quantities on order.
• Physician order must be kept in the member file and be available upon request.
• All other documentation requirements (timeliness, medical records, tests results, etc) are waived during emergency.
• Waive POA and need for new medical documentation for the replacement of medical equipment/supplies that have been lost, destroyed, damaged or otherwise rendered unusable or unavailable during emergency.

CMS Guidance 
COVID-19 Emergency Declaration Health Care Provider Fact Sheet (3/13/2020)
Start date: March 13, 2020
End date:  Continue up to the termination of the Governor’s Declaration of a State Emergency Order
Applies to: Medicare, MMP, DSNP, Commercial 
Excludes: Medicaid, ASO

Here are the guideline from CMS:
For Durable Medical Equipment Where Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) is lost, destroyed, irreparably damaged, or otherwise rendered unusable: 

• Contractors have the flexibility to waive replacements requirements such that the face-to-face requirement, a new physician’s order, and new medical necessity documentation are not required.
• Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced.
• Suppliers need to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable or unavailable as a result of the emergency.

HAP will continue to assess the situation and revise policies as needed or if government rulings require changes. 

How have you communicated with members, employers and providers?

Below is an outline of the ways we’ve communicated.

Members

We’ve posted the following information on hap.org:

• COVID-19 testing and treatment
• Getting care (virtual visits on telehealth)
• Prescription coverage
• Travel and quarantine
• Scam and fraud protection
• Helpful resources on the latest health and wellness news, tips and answers to questions by HAP experts, as well as helpful ideas to improve well-being

We’ve sent direct mail to members about in-home prescription delivery

We’ve called members at highest risk of food insecurity and social isolation. Actions range from assessing care management needs to offering free meals for up to two weeks. This will be offered through the State declared emergency.   

Employers 

Employers have access to the online information available for members, as well as the following specific employer information hap.org:

• Legislative information
• Premium payment
• Temporary staff changes
• Special enrollment periods
• Other coverage options
• Business resources with information on recent legislation, available resources and answers to questions about their HAP plan.

Providers 

Providers have access to the online information available for members, as well as the following specific provider information hap.org:

• HAP policy updates related to COVID-19 (in the newsroom)
• Business resources with information on recent legislation, available resources and answers to questions about their HAP plan.

Pharmacies

We’ve worked directly with our pharmacies on early medication refills and prescription home deliveries.

What are your Billing Guidelines for COVID-19 Related Services and Telehealth Services during the Public Health Emergency?

Updated Billing Guidelines for Outpatient Services for COVID-19 Cost Share Waiver

To ensure accurate claims payment, please follow the updated billing guidelines below for all HAP Commercial, ASO and Medicare products for outpatient services.

Important! For services provided through the end of the Public Health Emergency (PHE), you should use the CS modifier on applicable outpatient claim lines to show the service is subject to the cost-share waiver for COVID-19 testing-related services that result in an order for and are related to providing or administering a COVID-19 test.

Cost share will be waived when a provider:

• Submits a claim line with a CS modifier (professional, facility and telehealth) with a specific outpatient E&M or HCPCS code and if billed with suspected or likely exposure to COVID-19: Z20.822, as the primary diagnosis, as appropriate.
• Submits a claim line with procedure code S9083 with a CS modifier for Urgent Care services and if billed with suspected or likely exposure to COVID-19: Z20.822, as the primary diagnosis, as appropriate.
• Submits COVID-19 CPT/HCPCS testing codes on an outpatient claim if billed with suspected or likely exposure to COVID-19: Z20.822, as the primary diagnosis, as appropriate.
• Submits a claim line for COVID-19 specimen collection with a CS modifier on an outpatient claim and if billed with suspected or likely exposure to COVID-19: Z20.822, as the primary diagnosis, as appropriate. HAP continues to reimburse only when billed alone. We consider this service inclusive when billed with an E&M code.
• Submits each claim line with CS modifier appended for each additional lab other than COVID-19 diagnostic test when ordered specifically to determine a diagnosis of COVID-19 and if billed with suspected or likely exposure to COVID-19: Z20.822, as the primary diagnosis, as appropriate.
• Submits a claim line for COVID-19 CPT/HCPCS testing for pre-operative procedures. HAP supports correct coding guidelines and as such should be submitted with the following, as appropriate:
  • Z01.810 – Encounter for preprocedural cardiovascular examination
  • Z01.811 – Encounter for preprocedural respiratory examination
  • Z01.812 – Encounter for preprocedural laboratory examination
  • Z01.818 – Encounter for other preprocedural examination

COVID-19 testing for public health surveillance, employment purposes, and other testing not intended for individualized diagnosis or treatment of Covid-19:

• Submits a claim line for testing required for public health surveillance/screening, employment purposes or travel use Z11.52 as the primary diagnosis, as appropriate. This claim line will be denied as this is not a covered benefit.

Billing Guidelines for Telehealth Services During the Public Health Emergency

Our billing requirements for telehealth services are aligned with CMS.

Urgent Care Centers-Reimbursement for COVID 19 Vaccine Administration

Below are the covered codes for administration of COVID-19 vaccines.

Reimbursement

For dates of service November 1, 2020, and forward, we’ll follow the guidelines below to reimburse urgent care centers for COVID-19 vaccine administration.

Billing Guidelines for COVID-19 Vaccine Administration Only

To ensure accurate claims payment, please follow the vaccine administration and billing guidelines below for all HAP and HAP Empowered lines of business.

Providers cannot bill for vaccines supplied by the government under the CARES Act.

Vaccine Administration Billing Guidelines for Commercial and Medicaid Members

You can submit claims for administration of COVID-19 vaccines for commercial and Medicaid members. Please use the codes below.

Vaccine Administration Billing Guidelines for Medicare Advantage Members