Over-the-counter covid-19 test demonstration
Starting April 4, 2022 and through the end of the covid-19 public health emergency (phe), medicare covers and pays for over-the-counter (otc) covid-19 tests at no cost to individuals with part of medicare b, including those with medicare advantage (ma) plans (referred to on this website as “patients”).
in addition to helping prevent the spread of covid-19, the goal of this demonstration is to find out if medicare paying for over-the-counter covid-19 tests will improve access to testing and result in medicare savings or other program improvements.
what is covered
eligible vendors may distribute u.s. FDA-approved, licensed, or approved COVID-19 OTC tests for patients enrolled in Part B, including those enrolled in MA plans. Patients who only have Medicare Part A can get free OTC COVID-19 tests through other government-run programs, such as covidtests.gov, which operates through the United States Postal Service (USPS). or they may be covered through a private insurance plan, if they are enrolled in a plan.
Medicare-eligible patients will get these tests at no cost and their annual deductible, coinsurance, and copay will not apply.
how many tests are covered
Each medicare eligible patient can get up to 8 tests per calendar month until the phe ends. medicare will not pay for more than 8 over-the-counter tests in a month. If a patient has more than 8 tests in a calendar month, she may pay out of pocket for additional tests unless she has additional health coverage.
who can participate
Institutional and non-institutional ambulatory healthcare providers and providers may participate in the demonstration. Eligible health care providers and providers must be enrolled in Medicare and bill for these tests in a standard claims format (such as professional or institutional 837 format). participating eligible providers may not use lists of lists.
Eligible providers and vendors include:
- physicians and other non-physicians
- clinical/group practices
- hospital outpatient departments
- critical access hospitals (cahs)
- skilled nursing facilities (snfs)
- home health agencies (hhas)
- federally qualified health centers (fqhcs)
- rural health clinics (rhcs)
- opioid treatment programs (otps)
- independent laboratories
- independent renal dialysis centers
- comprehensive outpatient rehabilitation centers (corfs)
- mass immunizers (only those that bill in standard claim format)
- indian health service centers (ihs)
- pharmacies that are enrolled in part b as a particular type of entity (such as clia-certified laboratories, mass immunizers, or those under the enrollment of a professional, such as a nurse practitioner to provide health services). and ambulatory medical care). For example, if you currently manage and submit claims for services such as covid-19 immunizations, lab tests, and/or clinic visits, you can also bill under this demo for covid-19 otc tests. You can provide and bill OTC Covid-19 tests for anyone with Part B. they do not need to be an existing customer or get their prescriptions from you.
- institutional providers, such as inpatient hospitals or other hospital providers, when you provide testing after the patient is discharged discharge from hospitalization
Medicare does not cover over-the-counter covid-19 tests when billed through:
- those who are enrolled in medicare only as durable medical equipment prosthetics, orthotics, & supply provider (dmepos)
- providers who administer over-the-counter covid-19 tests to patients during a hospital stay, such as a hospital stay or snf stay
how to participate
Participation in this demonstration is voluntary. if you meet the criteria and want to participate:
- You do not need to sign a participation agreement to bill medicare for these tests.
- You initiate participation in the demonstration when you file a medicare claim for the covid-19 otc tests. .
- You do not need to complete a new enrollment if you are currently enrolled in Medicare and can provide outpatient health care services, such as lab tests, preventive immunizations, or other clinic visits.
- submit medicare claims using code hcpcs k1034. see “how to bill”.
- you will obtain the otc covid-19 tests yourself to provide to medicare patients. see “tips for providing evidence”.
what happens if I decide not to participate?
Providers and vendors who do not participate in this demonstration may continue to sell over-the-counter covid-19 tests to patients, including those enrolled in part b or ma plans.
tips for providing evidence
- only give patients tests when they ask for them. discuss the availability of tests and the limit of 8 tests per calendar month with your patients (or their caregivers).
- we encourage you to ask the patient if a provider or supplier has already given other tests of covid-19 otc in the current calendar month. If you are unsure or don’t know the limit, you can voluntarily give the patient an Advanced Beneficiary Notice of Non-Coverage (ABN) before taking an over-the-counter COVID-19 test.
- you as the patient can appeal the denial.
We will reject the payment if you:
- submit a claim for more evidence than the limit of 8 per calendar month. if we deny a claim for this reason, you may bill the patient directly for the excess testing.
- submit more than 1 claim or claim line per patient per day for the same service. see “how to bill” for more information.
how to invoice
Use code hcpcs k1034 to bill for a single test. this code applies to all covid-19 otc, fda-approved, authorized, or approved tests (that are self-administered with a sample that is collected):
- k1034 short description: self administration/collection of covid tests
- long descriptor: k1034: provision of covid-19 tests, self administration and self collection without prescription, fda approved, authorized or deleted, account of a test
If you perform more than 1 test on a patient on the same day, please adjust the quantity and amount billed for the number of tests on a single claim line. do not submit multiple claims or multiple claim lines for one patient on the same day for the same service.
Your patients do not need a doctor’s order or oversight of the otc tests provided in the demo.
- use the same npi, tin, or ptan that you use when billing for flu, pneumococcal, or covid-19 vaccines
- revenue codes:
- use code 0300
- corf providers: use code 0274
- Hospital-Based: Bill tests through your hospital
- Standalone or Independent: Bill tests on a cms-1500, as you would other normal lab services
- an npi billing provider
- “self-referred” in the corresponding name field
how to bill ma plan patients
for patients enrolled in a ma plan, submit claims to original medicare through your medicare administrative contractor (mac). use your patients’ medicare beneficiary identifiers (mbis) (not their medicare advantage plan member IDs) to bill original medicare.
- You can bill multiple tests, including single-test and multi-test packages.
- If a package has more than one test, be sure to bill for the total number of tests ( 1 test = 1 unit). for example, if a package has 2 proofs, submit a claim for 2 units of hcpcs code k1034.
- all types of payers, including private insurance and medicaid programs, can use hcpcs code k1034 .
- submit claims using the standard claim format (the professional or institutional 837 format).
- if using the free pc-ace billing software, add code hcpcs k1034 to submit electronic claims.
- you cannot use list bills to bill medicare for otc covid-19 tests.
- if a patient files a claim, we will return it to them. they may then ask you to submit a claim for processing. if we deny their claim, the patient may appeal this decision once a determination is made. patients will obtain a determination through the medicare summary notice. providers will receive a notice of payment.
medicare payment amount
- we will pay a flat national payment rate of $12 per non-prescription covid-19 test
- we will not geographically adjust this payment rate
- if you typically charge less than $12 per test, then we will pay the lesser of the 2 amounts
- you must accept the medicare payment amount as payment in full and not collect any additional amounts from patients for tests provided within the quantity limit
how to charge
We will pay you directly when you submit valid claims for eligible Medicare patients who request tests and have not reached the covid-19 otc test quantity limit of 8 tests per calendar month.
submit only 1 claim per patient per day. if you have a patient perform more than 1 test on the same day, please adjust the quantity and amount billed for the number of tests.
We will pay claims in the order we receive them. be sure to file claims promptly. We will only pay claims with dates of service beginning on or after April 4, 2022, through the last day of covid-19 phe.
If you participate, you accept:
- submit a claim for payment
- receive payment as a participating eligible provider under the demonstration
- accept payment in full (the fixed national payment rate of $12 per test or any lesser amount than you would normally charge)
- not collect any additional payment from patients for tests you provide within the limit of 8 per calendar month