FAQs for COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment and Vaccine Administration

The Administration is providing support to health care providers fighting the COVID-19 pandemic through the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program. This program provides reimbursements on a rolling basis directly to eligible providers for claims that are attributed to the testing, treatment, and vaccine administration for COVID-19 for uninsured individuals.

The following pieces of bipartisan legislation provide funding for the program:

• The Families First Coronavirus Response Act or FFCRA (P.L. 116-127) and the Paycheck Protection Program and Health Care Enhancement Act or PPPHCEA (P.L. 116-139), which each appropriate $1 billion to reimburse providers for conducting COVID-19 testing for uninsured individuals;
• The Coronavirus Aid, Relief, and Economic Security (CARES) Act (P.L. 116-136), which provides $100 billion in relief funds, including to hospitals and other health care providers on the front lines of the COVID-19 response, the PPPHCEA, which appropriated an additional $75 billion in relief funds, and the Coronavirus Response and Relief Supplemental Appropriations (CRRSA) Act  (P.L. 116-260), which appropriated an additional $3 billion (collectively, Provider Relief Fund).
  • Within the Provider Relief Fund, a portion of the funding will be used to support health care-related expenses attributable to COVID-19 testing for the uninsured and the treatment of uninsured individuals with COVID-19.  A portion of the funding will also be used to administer to uninsured individuals Food and Drug Administration (FDA)-authorized COVID-19 vaccines under an Emergency Use Authorization (EUA) or FDA-licensed COVID-19 vaccines under a Biologics License Application (BLA).

The FFCRA Relief Fund includes $2 billion ($1 billion appropriated through the Families First Coronavirus Response Act and $1 billion appropriated through the Paycheck Protection Program and Health Care Enhancement Act) to reimburse providers for COVID-19 testing for uninsured individuals. Additionally, the CARES Act established a Provider Relief Fund and appropriated $100 billion to the fund. The PPPHCEA appropriated an additional $75 billion and the CRRSA appropriated an additional $3 billion to the Provider Relief Fund. A portion of the Provider Relief Fund will be used to reimburse providers for COVID-19 testing for the uninsured, for treating uninsured individuals with COVID-19 and for administering FDA-authorized or licensed COVID-19 vaccine to uninsured individuals.

No. The HRSA COVID-19 Uninsured Program is a claims reimbursement program for health care providers which does not meet the definition of a "health plan" as defined in section 1171(5) of the Social Security Act and in 45 C.F.R. § 160.103 in that the program has no relationship with individuals that would legally obligate the program to pay claims for some or all of the health care provided to those individuals. Therefore, the program is not subject to HIPAA requirements.

The HRSA COVID-19 Uninsured Program does not provide coding guidance to providers. Rather, the program provides billing guidance to allow providers to identify and submit only claims eligible for reimbursement under this program, which is exclusively for reimbursing providers for COVID-19 testing of uninsured individuals and treatment for uninsured individuals when COVID-19 is the primary reason for treatment, or for vaccine administration to uninsured individuals. HRSA has developed the following guidance for claims reimbursement submission:

• For dates of service or discharges on or after April 1, 2020, providers will use primary diagnosis U07.1 to indicate COVID-19 is the primary reason for treatment except for pregnancy for which providers will use O98.5 as primary diagnosis and U07.1 as the secondary diagnosis.
• For dates of services or discharges prior to April 1, 2020, there is no equivalent diagnosis to indicate COVID-19 is the primary reason for treatment. To address this issue, HRSA has established separate guidance for this program to use B97.29 as the primary diagnosis when COVID-19 is the primary reason for treatment except for pregnancy for which providers would use O98.5 as the primary diagnosis and B97.29 as the secondary diagnosis (similar to how U07.1 is used).

HRSA recognizes that the use of B97.29 as the primary diagnosis as described above is different from the ICD-10-CM Official Coding Guidelines – Supplement for Coding encounters related to COVID-19 Coronavirus Outbreak. However, as previously stated, HRSA’s COVID-19 Uninsured Program is not a health plan.

Health care entities who have conducted COVID-19 testing of uninsured individuals, provided treatment to uninsured individuals with a COVID-19 primary diagnosis, or administered a licensed or authorized COVID-19 vaccine to uninsured individuals on or after February 4, 2020, can request claims reimbursement through the program electronically and will be reimbursed generally at Medicare rates, subject to available funding.

For claims for COVID-19 Testing and Testing-Related Items and Services, a patient is considered uninsured if 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 the services were rendered. For claims for treatment for positive cases of COVID-19, a patient is considered uninsured if the patient did not have any health care coverage at the time the services were rendered. For claims for vaccine administration, this means that the patient did not have any health care coverage at the time the service was rendered.

Health care providers are not required to confirm immigration status prior to submitting claims for reimbursement. Health care providers who have conducted COVID-19 testing of any uninsured individual, provided treatment to any uninsured individual with a COVID-19 primary diagnosis, or administered a licensed or authorized COVID-19 vaccine to an uninsured individual for dates of service or admittance on or after February 4, 2020, may be eligible for claims reimbursement through the program as long as the service(s) provided meet the coverage and billing requirements established as part of the program.

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 provided. For claims for COVID-19 testing and testing-related items and services, this means that the patient did not have coverage through an individual, or employer-sponsored, a federal healthcare program, or the Federal Employees Health Benefits Program. For claims for treatment of positive cases of COVID-19, this means that the patient did not have any health care coverage. For claims for vaccine administration, this means that the patient did not have any health care coverage. Providers may submit a claim for uninsured individuals before Medicaid eligibility determination is complete. However, if the provider learns that the individual is retroactively enrolled in Medicaid as of the date of service, the provider must return the payment to HRSA.

The new optional COVID-19 testing eligibility group, added by section 6004(a)(3) of the FFCRA at section 1902(a)(10)(A)(ii)(XXIII) of the Act, is similar to other optional eligibility groups under which states can elect to furnish a targeted set of benefits to eligible individuals. To reimburse providers for the covered services, a state must elect to adopt this group under its state plan. States that do so can then reimburse providers enrolled in their Medicaid program for in vitro diagnostic testing and other COVID-19 testing-related services furnished to individuals whom the agency has determined are eligible under the new group. For more information on the eligibility requirements for the optional COVID-19 testing eligibility group, covered benefits, the availability of hospital presumptive eligibility for the new group, and the availability of 100 percent Federal Medical Assistance Percentage (FMAP) for the testing services provided to individuals eligible under the optional COVID-19 testing eligibility group, see these FAQs (PDF – 646KB). For more information on strategies to assist states in operationalizing this group, see this guidance (PDF – 245 KB).

The Health Resources and Services Administration (HRSA) is administering a separate program, referred to as the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (HRSA COVID-19 Uninsured Program). This program provides reimbursement directly to eligible providers and has two components:

1. Reimbursement for COVID-19 testing services. This component, authorized via the FFCRA and the Paycheck Protection Program and Health Care Enhancement Act (P.L. 116-139) (PPPHCEA), reimburses providers for conducting COVID-19 testing for uninsured individuals. The FFCRA and the PPPHCEA each appropriated $1 billion (for a total of $2 billion) for this purpose. Additionally, a portion of the Provider Relief Fund mentioned below will also support COVID-19 testing of the uninsured.
2. Reimbursement for COVID-19 treatment services. This component is authorized via the CARES Act, which provides $100 billion in relief funds for hospitals and other health care providers, including those on the front lines of the COVID-19 response. The PPPHCEA appropriated an additional $75 billion and the CRRSA appropriated an additional $3 billion in relief funds. Within the Provider Relief Fund, a portion of this funding is being used to support health care-related expenses attributable to the treatment of uninsured individuals with COVID-19, COVID-19 testing of the uninsured, and COVID-19 vaccine administration to the uninsured.

To access these funds, health care providers must enroll in the program as a provider participant. Once they have done so, they can submit claims for direct reimbursement for COVID-19 testing and treatment services furnished to uninsured individuals on or after February 4, 2020, and for COVID-19 vaccine administration fees for the uninsured.

Note that individuals who are enrolled in a state's Medicaid program, including uninsured individuals enrolled in the new optional COVID-19 testing eligibility group, are not considered uninsured for purposes of provider reimbursement of COVID-19 testing services through the HRSA-administered program. Providers can submit claims through the HRSA-administered program for COVID-19 treatment services and COVID-19 vaccine administration provided to uninsured individuals who are enrolled in the new optional COVID-19 testing eligibility group but who do not have coverage for COVID-19 treatment and vaccine administration services.

Health care providers who have conducted COVID-19 testing of uninsured individuals, treated uninsured individuals with a COVID-19 primary diagnosis, or administered COVID-19 vaccine to uninsured individuals on or after February 4, 2020, may be eligible for claims reimbursement through the program as long as the service(s) provided meet the coverage and billing requirements established as part of the program.

Under the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program (Uninsured Program), health centers are eligible to seek reimbursement for conducting COVID-19 testing, providing treatment for uninsured individuals with a COVID-19 diagnosis, or for administering a licensed or authorized COVID-19 vaccine to uninsured individuals. Health Center Program requirements include an obligation under section 330(k)(3)(F) for health centers to make "every reasonable effort to collect appropriate reimbursement for its costs in providing health services" from potential payers (see also [Chapter 16: Billings and Collection, Health Center Compliance Manual]). Health Centers are also required to provide financial and budget information relating to nongrant fund program income. These requirements do not impact a health center’s eligibility to submit reimbursement claims to the Uninsured Program.

If a health center also receives Ryan White HIV/AIDS Program grant funds under title XXVI of the Public Health Service (PHS) Act, please refer to the HRSA HIV/AIDS Bureau website for further information. In addition, please continue to ensure that you are allocating and tracking appropriate grant funds.

In accordance with the requirements of the Uninsured Program, in order to seek reimbursement, a health center must agree to the following as attested at registration:

• You will accept defined program reimbursement as payment in full.
• You agree not to balance bill the patient.

Therefore, if a health center accepts reimbursement from the Uninsured Program, it may not balance bill/charge the patient.

For questions about Health Center Program billing and collections, sliding fee discount program, and other requirements please contact Health Center Program Support. More information about the Health Center Program is also available, including FAQs related to COVID-19 and health centers..

Ryan White HIV/AIDS Program (RWHAP) recipients are prohibited from submitting claims for reimbursement for services provided to RWHAP clients to the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program.

The FY 2020 CARES Act funding provided to Ryan White HIV/AIDS Program (RWHAP) recipients through RWHAP Part A should be used for preventing, preparing for, and responding to COVID-19, as needs evolve for clients of RWHAP recipients. The COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program, funded through the Families First Coronavirus Response Act, Paycheck Protection Program, and Health Care Enhancement Act, and the CARES Act, and distributed through HRSA, is not a state compensation program, an insurance policy, a federal or state health benefits program, or an entity that provides health services on a prepaid basis. As such, it does not trigger the payer of last resort provision codified in the RWHAP legislation. RWHAP providers should use their COVID-19 CARES Act funding specifically authorized for the RWHAP patient population, and are prohibited from accessing the Provider Relief Fund for these same services. For those RWHAP providers that provide services to a broad range of patients, claims may be submitted for services provided to non-RWHAP eligible clients.

Pharmacies/pharmacists and those operating under their supervision who are legally authorized, including under the Public Readiness and Emergency Preparedness Act, to order and/or administer testing or vaccination services are eligible to request reimbursement for testing or vaccination administration under this program.

No. HHS considers such individuals, when they receive services through an I/T/U, to be enrolled in a federal health care program, as that term is defined in Social Security Act § 1128B(f). That is, they are not considered Uninsured Individuals for the Families Frist Coronavirus Response Act (FFCRA) Relief Fund (i.e., the Testing Distribution) because the FFCRA defines who is uninsured, and the statute excludes individuals who are enrolled in a federal health care program, as that term is defined in Social Security Act § 1128B(f). Individuals who are I/T/U beneficiaries are also not considered Uninsured Individuals for the CARES Act Provider Relief Fund (i.e., the Treatment Distribution, vaccine administration). However, the FFCRA appropriated a separate fund to cover, without the imposition of any cost-sharing requirements, the cost of providing COVID-19 Testing and Testing-Related Items and Services for individuals who are I/T/U beneficiaries. In addition, I/T/Us may submit claims for reimbursement for testing, treatment, and/or vaccine administration they provide to non-I/T/U beneficiaries who otherwise meet the definition of "uninsured individuals" in the Terms and Conditions for the Testing (Testing Attestation ) and Treatment (Treatment Attestation ) of the Uninsured Distribution.

Any provider who is on the Office of the Inspector General U.S. Department of Health and Human Services List of Excluded Individuals/Entities and/or any provider who has had their Medicare enrollment revoked by the Centers for Medicare & Medicaid Services is ineligible to receive funding from the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program.

For dates of service or admittance on or after February 4, 2020, reimbursement will be made for qualifying testing for COVID-19, treatment services with a primary COVID-19 diagnosis or for qualifying COVID-19 vaccine administration, as determined by HRSA (subject to adjustment as may be necessary), including the following:

• Specimen collection, diagnostic and antibody testing.
• Testing-related visits including in the following settings: office, urgent care or emergency room or telehealth.
• Treatment, including office visit (including telehealth), emergency room, inpatient, outpatient/observation, skilled nursing facility, long-term acute care (LTAC), acute inpatient rehab, home health, DME (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.

Claims will be subject to Medicare timely filing requirements.

For more details, see billing codes information.

The HRSA COVID-19 Uninsured Program will align claims reimbursement for monoclonal antibody therapy with the CMS guidance issued on November 10, 2020.  Per CMS’s Medicare Monoclonal Antibody COVID-19 Infusion Program Instruction, “During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA).” View information regarding coding and pricing. (PDF - 200 KB)

Health care providers who have conducted COVID-19 testing for uninsured individuals, provided treatment to uninsured individuals with a primary COVID-19 diagnosis on or after February 4, 2020, or administered a licensed or authorized COVID-19 vaccine to uninsured individuals, can request claims reimbursement through the program electronically and will be reimbursed generally at Medicare rates, subject to available funding. Steps will involve: enrolling as a provider participant, checking patient eligibility, submitting patient information, submitting claims, and receiving payment via direct deposit.

To participate, providers must attest to the following at registration:

• They have checked for health care coverage eligibility and confirmed that the patient is uninsured. They have verified that the patient does not have coverage such as individual, employer-sponsored, Medicare or Medicaid coverage, and no other payer will reimburse them for COVID-19 testing and/or care or vaccine administration for that patient.
• They will accept defined program reimbursement as payment in full.
• They will agree not to balance bill the patient.
• They will agree to program terms and conditions and may be subject to post-reimbursement audit review.

All claims submitted must be complete and final and no interim bills or corrected claims will be accepted. There will be no adjustments to payment once claims reimbursements are made.

Reimbursement pricing and policies under this program for eligible services, as determined by HRSA (subject to adjustment as may be necessary), are described below.

• Reimbursement will be based on current year Medicare fee schedule rates except where otherwise noted.
• Publication of new codes and updates to existing codes will be made in accordance with published CMS guidance.
• For any new codes where a CMS published rate does not exist, claims will be held until CMS publishes corresponding reimbursement information.
• Claims submitted electronically for professional services will be priced as follows:
  • Services will price with current year CMS pricing with geographic adjustments, as applicable.
  • If no geographic adjustments are applicable, services will price with current year CMS national pricing.
  • COVID-19 testing and specimen collection procedures will price in accordance with rates published in the CARES Act (PDF – 956 kb) and CMS interim final rules.
• Claims submitted electronically for facility services will generally price according to traditional Medicare reimbursement, examples of exceptions are noted below:
  • For purposes of this program, facility reimbursement based on IPPS will not include the 20% increase to the DRG weight for COVID-19 diagnoses U07.1 and B97.29 authorized by Section 3710 of the Cares Act.
  • For purposes of this program, reimbursement rates for facilities not paid on IPPS [Critical Access Hospitals (CAHs), Rural Health Clinics (RHCs), Children’s Hospitals, and PPS Exempt Cancer Hospitals] will not be updated after February 4, 2020.
  • Home health services will be priced based on a per-visit methodology by service type as established by the program:
    • All Medicare-eligible service categories: PT/OT/ST – $90
    • Nursing services – skilled nursing – $90
    • Nursing services – licensed practical nurse – $60
    • Medical social services – $90
    • Home health aide – $30
    • Home infusion therapy – PICC/midline supplies $70, PICC/midline placement $110
• For purposes of this program, the following rates will apply for reimbursement of ambulance claims with a primary diagnosis of COVID-19:
  • Ground ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Water ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Air ambulance: facility price of $2,300 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
• Vaccine administration fees will be priced based on Medicare rates and are outlined below:
  • Administration of a single-dose COVID-19 vaccine - $28.39 
  • Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94 
  • Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39

Yes. The program reimburses providers for COVID-19 testing, treatment, or vaccine administration fees for uninsured individuals; therefore, any money collected from the individual must be returned to the individual if the provider received funding for that patient through this program.

This requirement is included in the Terms and Conditions that the provider signs in order to enroll in the program.