In statements issued in recent days, the US Department of Health and Human Services (HHS) has described the timeline and parameters for a program reimbursing healthcare providers for costs they incur in furnishing COVID-19 testing and treatment to uninsured individuals. HHS is referring to this program as the Claims Reimbursement for Testing and Treatment to Health Care Providers and Facilities Serving the Uninsured Program (the “Program”).
Program funds to cover COVID-19 treatment are one of various “targeted allocations” that HHS intends to make under the Provider Relief Fund, an appropriation of $100 billion authorized in the Coronavirus Aid, Relief, and Economic Security (“CARES”) Act. In addition, Program funds to reimburse COVID-19 testing are drawn in part from a $1 billion appropriated to HHS for this purpose in the Families First Coronavirus Response Act.
The Program is being administered by the HHS Health Resources and Services Administration (HRSA), which contractually delegated some responsibilities to UnitedHealth Group. On April 27, HRSA released informational guidance on the program addressing the following. HRSA issued a fact sheet, COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured; as well as an accompanying document, Frequently Asked Questions for Coronavirus Aid, Relief, and Economic Security (CARES) Act Provider Relief Fund.
Following are some basic features of the Program.
- Eligibility: Providers are eligible to sign up for payment for COVID-related services to the uninsured under the Program if they “hav[e] conducted COVID-19 testing or provided treatment for uninsured individuals with COVID-19 on or after February 4, 2020.” Providers who are on the HHS list of excluded individuals/entities or have had their Medicare enrollment revoked by CMS are ineligible to receive funding. We do not see any indication that providers need to be already enrolled in Medicare in order to be eligible to receive the funding.
- Services: The Program will pay for “qualifying testing for COVID-19.” This includes testing-related visits taking place in an office, urgent care or emergency room setting, or via telehealth, as well as specimen collection, diagnostic and antibody testing. As for treatment, the Program will pay for the following, where COVID-19 is the primary diagnosis: office visits (including via telehealth); care and encounters in other settings (emergency room, inpatient, outpatient/observation, skilled nursing facility, longterm acute care (LTAC) facilities, home health, durable medical equipment (including ventilators and oxygen); emergency and non-emergency ground ambulance transportation; and, once they become available, FDA-approved drugs for COVID-19. The Program will not cover any services not typically covered by Medicare or any service (except certain services for pregnant women) where COVID-19 is not the primary diagnosis.
- Amount of Payment: HHS states that providers will be “reimbursed generally at Medicare rates, subject to available funding.” HHS additionally states: “Reimbursement will be based on current year Medicare fee schedule rates except where otherwise noted.” HHS notes that the services will be priced with current year CMS pricing with geographic adjustments, as applicable.
- Registering as a Program Provider: As described by HRSA (COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsured), steps required in order to receive payment will involve “enrolling as a provider participant, checking patient eligibility, submitting patient information, submitting claims, and receiving payment via direct deposit.” As to “checking patient eligibility,” providers must attest that they have confirmed that the patient is uninsured (i.e., the patient does not have individual or employer-sponsored insurance and “no other payer will reimburse [the provider] for COVID-19 testing and/or care for that patient”); and that they agree to accept Program reimbursement as payment in full and not to balance bill the patient.
- Post-Claim Review and Audit: Providers must agree to Program terms and conditions (see below) and acknowledge that they may be submit to post-reimbursement audit review. Notably, HHS states that all claims submitted are final and “no interim bills or corrected claims will be accepted”; this is different from standard Medicare policies, where claims may be corrected after filing. All claims must be submitted electronically.
- Effective date: While the HHS documents do not clearly specify the effective date of the Program with respect to coverage for outpatient services, it appears to us that HHS intends to cover services rendered on or after February 4, 2020.
- Timeline: HHS allowed providers to begin enrolling in the program on Monday, April 27. HRSA and UnitedHealth Group will begin providing technical assistance on Wednesday, April 29. HHS states: “Providers can begin submitting claims on May 6 and can expect to begin receiving reimbursements by mid-May.”
- Terms and Conditions: Providers must accept numerous terms and conditions in order to participate in the Program, set forth here. Among the more notable of the terms are the following: (1) the provider must certify that it “will not use the Payment to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse”; (2) the provider must submit quarterly reports to HHS detailing total amounts received from HHS under the federal coronavirus response legislation; and (3) the provider must certify “that it will not engage in ‘balance billing’ or charge any type of cost sharing for any items or services provided to Uninsured Individuals receiving care or treatment for a positive diagnosis of COVID-19 for which the Recipient receives a Payment from the Relief Fund. The Recipient shall consider Payment received from the Relief Fund to be payment in full for such care or treatment.”
Providers should carefully review Program requirements, as well as the terms and conditions document, in evaluating potential participation in the Program. For federally qualified health centers (FQHCs) in particular, the HHS guidance leaves unanswered numerous questions, including whether the form of payment under the Program will be equal to FQHCs’ Medicare prospective payment system (PPS) rates, or equivalent to Physician Fee Schedule rates; and, how the prohibition on “balance billing” in the terms and conditions interacts with FQHCs’ obligations relating to charges and discounts to patients under Section 330 of the Public Health Service Act.
Questions? If you have any questions about this update or other matters, please contact Susannah Vance Gopalan (Partner) or call (202) 466-8960.
 CARES Act, Pub. L. 116-136 (Mar. 27, 2020), Div. B, Title VIII. In the law, the fund is termed the Public Health and Social Services Emergency Fund.
 Families First Coronavirus Response Act, Pub. L. 116-127 (Mar. 18, 2020), Title V.