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The purpose of this bulletin is to clarify when COVID-19 (SARS-CoV-2) testing must be covered without cost-sharing under Emergency Rule H-2020-03-E, which requires health insurers to cover SARS-CoV-2 testing performed by the Centers for Disease Control (CDC), the Vermont Department of Health (VDH), or a laboratory approved by CDC or VDH with no co-payment, coinsurance, or deductible requirements for members “[w]hen medically necessary or directed by the state or federal government.” Self-insured or publicly funded health care benefit plans offered through employers are encouraged but not required to comply with this bulletin. Members of employer-sponsored plans should consult their plan administrator for clarification on covered testing.
Clinical decisions regarding testing should be made by the member’s health care provider and may include testing of individuals with signs or symptoms compatible with COVID-19, as well as asymptomatic individuals based upon current clinical guidelines. Due to the unprecedented nature of the COVID-19 crisis and the ongoing need to eliminate obstacles to testing, all claims for FDA-authorized SARS-CoV-2 testing with the following procedure codes shall process without member cost-sharing:
COVID-19 tests: U0001, U0002, U0003, U0004, 87635
Antibody tests: 86318, 86328, 86769
Specimen collection: G2023, G2024
In addition, office and hospital charges associated with the encounter and date of service shall process without member cost-sharing when one of the following diagnosis codes is the primary diagnosis on the claim:
Z03.818: Encounter for observation for suspected exposure to other biological agents ruled out (possible exposure to COVID-19);
Z11.59: Encounter for screening for other viral diseases (asymptomatic);
Z20.828: Contact with and (suspected) exposure to other viral communicable (confirmed exposure to COVID-19).
Health insurers are expected to establish all appropriate contractual, billing, and other administrative arrangements to reimburse providers for the cost of collecting specimens and conducting appropriate testing. This bulletin shall remain in effect for 90 days or longer as ordered by the Commissioner.
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Michael S. Pieciak, Commissioner
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