COVID-19 Guidance for Medicaid Providers
- Guidance is also available in Portable Document Format (PDF)
New York State (NYS) Medicaid Pharmacy Policy and Billing Guidance for At Home COVID-19 Testing Coverage
Coverage Changes are Effective February 8th, 2022
Updates are highlighted
Effective December 13, 2021, NYS Medicaid will cover over-the-counter (OTC) COVID-19 diagnostic and screening tests that provide "at-home" results for reimbursement with no member cost sharing. Effective January 10, 2022, a fiscal order is not required for the first 8 tests per month. Additional tests may be covered with a fiscal order, when medically necessary. Coverage will be provided for OTC FDA-authorized COVID-19 test kits that are used in accordance with the Centers for Disease Control and Prevention (CDC) recommendations for antigen detection. This policy applies to both Medicaid fee for service (FFS) and Medicaid Managed Care (MMC) and will remain in effect until the end of the COVID-19 Public Health Emergency.
NYS Medicaid Policy for Coverage:
- Covered OTC test kits must be authorized by the FDA for use in both symptomatic and asymptomatic patients and allow for self-collection without medical observation.
- Two (2) OTC tests per claim, with no refills (a test kit may contain two tests and is considered two OTC tests).
- Up to eight (8) OTC tests per month can be requested by a member at the pharmacy, without a fiscal order.
- If medically necessary, additional OTC tests will be covered with a fiscal order by a Medicaid-enrolled practitioner (which includes all the same information contained on a prescription). Refills will not be allowed.
- For FFS Medicaid only: Quantities greater than 8 tests per month will require verification that the fiscal order was obtained. Pharmacies may provide verification by calling the Magellan Clinical Call center at, 1-800-343-9000. The call center staff is available 24 hours a day, 7 days per week.
NYS FFS Pharmacy Billing for COVID-19 Test Kits:
Pharmacies may bill using the National Drug Codes (NDCs), which have been derived by using the Universal Product Code (UPC). For a list of tests that are covered, providers can perform a search using the eMedNY formulary search page. Select "Description" in the dropdown field and type in "COVID" to return all tests on the formulary.
Table 1 - Billing Instructions for COVID Tests
| NCPDP D.0. Claim Segment Field* | Value |
|---|---|
| 436-E1 (Product/Service ID Qualifier) | Enter a value of "03" (NDC) |
| 407-D7 (Product/Service ID) | Enter one applicable NDC from Table 2 |
| 444-E9 (Pharmacist ID) | Enter Prescriber National Provider Identifier (NPI) number |
| 411-DB (Prescriber ID) | Please leave field blank* |
* The NCPDP D.0 Companion Guide can be found on the eMedNY 5010/D.0 Transaction Instructions web page.
Please see the July 2020 Medicaid Update for further guidance on origin code and serial number values that must be submitted on the claim. In the origin code field use "5" and the corresponding serial number of "99999999" for "Pharmacy dispensing" when applicable for non-patient specific orders.
For quantities greater than 8 test per month which require a fiscal order, the NPI of the Medicaid-enrolled practitioner is required
Table 2 - OTC COVID-19 Tests Reimbursement
| Reimbursement* | Tests** per kit |
|---|---|
| Up to $24 | 2 |
| Up to $12 | 1 |
*Reimbursement for each test will be the lower of the maximum reimbursement amount or the Usual and Customary (U&C) price charged to the general public. In accordance with 42 C.F.R. § 447.512(b), pharmacies must provide a (U&C) price when submitting pharmacy claims for prescription and OTC (nonprescription) items. U&C is defined as the lowest price charged to the general public after all applicable discounts, including promotional discounts and discounted prices associated with loyalty programs.
**As more test kits become available the formulary will be updated here. For further information regarding COVID -19 tests access the following: FDA Emergency Use Authorizations for Medical Devices.
Reminder: The Medicaid program is the payer of last resort and providers should take reasonable measures necessary to ensure that all available options for coverage, including free at-home COVID tests from COVIDtests.gov and third-party insurance, are utilized prior to submitting claims to the Medicaid program.
Medicaid Managed Care (MMC)Coverage and Billing
The Medicaid coverage policy applies to all types of plans, without member cost sharing. The COVID-19 testing billing instructions are specific to Medicaid FFS. Individual MMC plan billing guidance for COVID-19 testing and specimen collection for pharmacies, is posted on the Medicaid Managed Care Pharmacy Benefit Information Center. Providers can select the MMC plan in question and then select the COVID Testing
Pharmacy Billing Guidance hyperlink to get the plan-specific guidance page on their website. Providers can also access this information on the individual MMC plan websites. For MMC billing questions unanswered by using these resources, please contact the individual plan using the information in the link above.
Additional Information
- For Medicaid FFS billing questions, please contact the eMedNY Call Center at (800) 343-9000.
- For Medicaid FFS Pharmacy Policy questions, please contact ppno@health.ny.gov.
- Information on fiscal orders and reimbursement can be found in the FFS Medicaid Pharmacy Manual.
- Information regarding COVID-19 testing at pharmacies can be found here: Medicaid FFS Policy and Billing Guidance for COVID-19 Testing and Specimen Collection at Pharmacies.
