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How does the HRSA COVID-19 Uninsured Program process claims for Medicaid enrollees who have limited Medicaid benefits (e.g., those enrolled in Medicaid for family planning benefits)?

How does the HRSA COVID-19 Uninsured Program process claims for Medicaid enrollees who have limited Medicaid benefits (e.g., those enrolled in Medicaid for family planning benefits)?

The American Rescue Plan Act of 2021 (ARPA, P.L. 117-2) included a requirement that most Medicaid limited-benefit plans cover COVID-19 vaccine administration, effective March 11, 2021.  ARPA also required Medicaid limited COVID-19 testing plans to cover COVID-19 treatment.  For more information, see the CMCS Informational Bulletin (PDF - 317 KB).

The HRSA COVID-19 Uninsured Program reimburses eligible claims for COVID-19 testing, treatment, and vaccination for individuals with limited Medicaid benefits if the Medicaid plan does not cover these services. HRSA's contractor, UnitedHealth Group (UHG), checks if the patient on the claim has other health care coverage using standard eligibility transactions. Currently, if UHG finds the patient has Medicaid coverage with limited benefits, the program reimburses the claim if otherwise eligible, but conducts coordination of benefits after payment to verify the patient’s Medicaid plan did not cover the COVID-19 services on the claim. If the Medicaid plan covered services that the Uninsured Program reimbursed, the program would offset the overpayment against any pending claims from the provider; if an offset is not possible, the provider must return the overpayment.

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