On January 30, 2023, the federal government announced the COVID-19 public health emergency (PHE) will end on May 11, 2023. In alignment with expiration of the PHE, Blue Cross NC will update coverage accordingly, noting vaccines, tests and their respective administration will be covered in alignment with each individual’s benefits, effective May 12, 2023.
Commercial Individual and Group Health Plans
Effective May 12, 2023, the following coverage will apply to individual and group health plans. This coverage brings our administration of these plans into compliance with federal law. Blue Cross NC will administer plans to:
- cover both the cost of the COVID-19 vaccine and vaccine administration at 100% when members receive the COVID-19 vaccine at an in-network provider as part of the health plan’s preventive care benefits.
- cover COVID-19 tests that are administered by a provider, based on each individual’s insurance plan. Members may be responsible for a portion of their costs to include copayments, coinsurance and deductible amounts.
Also effective May 12, 2023:
- Blue Cross NC will no longer administer plans to cover the cost of over the counter (OTC) COVID-19 tests.
- For over the counter (OTC) COVID-19 tests, members will be responsible for the cost and can pay or be reimbursed under health care flexible spending arrangements (health care FSAs), health care savings accounts (HSAs), health care reimbursement arrangements (HRAs), or Archer medical savings accounts (Archer MSAs).
Medicare Advantage Health Plans
- COVID-19 vaccine administration fees will continue to be paid under Part B, and providers will continue to be reimbursed $41.25, the rate established by the Centers for Medicare and Medicaid Services (CMS).
- In addition to the vaccine administration fee, Blue Cross NC will continue to participate in the Centers for Medicare and Medicaid Services (CMS) incentive program where providers are eligible for an additional $36.85 payment per dose for the administration of the vaccine in home settings for Medicare members, encouraging more members to get vaccinated and more providers to participate in vaccination efforts. This will be in effect through 2023. Providers that administer the COVID-19 vaccine at home for commercial members are not eligible for this additional payment.
Healthy Blue (Medicaid) Plans
- Medicaid will continue to cover the cost of the COVID-19 vaccine and vaccine administration, with no member cost-share for Healthy Blue members through September 30, 2024.
- If members receive the COVID-19 vaccine at an out-of-network provider, they may be responsible for the cost of the vaccine and/or vaccine administration based on their individual preventative care benefits.
Reimbursement for Vaccine Counseling
Counseling is included in any vaccine administration, per code definition. Effective May 12, Blue Cross NC will not reimburse CPT code 99401 when billed separately to counsel commercial members on the benefits of receiving the COVID-19 vaccine.
- CPT code 99401 is not specific to counseling for COVID-19 vaccines because counseling is inclusive and already built into the administration (CPT code 90460), per the code descriptor.
- If counseling is provided for COVID-19 or any other vaccine, outside of a vaccine that was actually administered, we do consider that separate counseling reimbursable, but it must be appended with an appropriate modifier, such as 25 or 59, to indicate it is separate and distinct.
For more information, please review our Commercial Reimbursement Policy (PDF).
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