LifeWise Assurance Company Student Insurance Response to COVID-19

LifeWise Student Insurance is here to support members, employers, and healthcare providers during the coronavirus (COVID-19) outbreak.

Updates as of February 8, 2023

• The federal Public Health Emergency (PHE) ends on May 11, 2023. See the new section on PHE.
• Changed vaccine counseling end date from October 4 to October 31.
  
• The Novavax vaccine was given EUA approval on July 20, 2022, for people ages 18 and up. It's a two-dose series given three weeks apart. A booster dose for people ages 18 and up was approved on October 19, 2022.
  
• New bivalent boosters from Moderna (ages 6 months and up) and Pfizer (ages 6 months and up) are now available. There are new codes available for these boosters.
• A Pfizer-BioNTech vaccine was authorized for children 6 months to 4 years and a Moderna vaccine was authorized for children 6 months to 5 years. 

COVID-19 Key Dates

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Frequently asked questions about COVID-19 and health plan coverage

Ending the Public Health Emergency (PHE) for COVID-19

Is the public health emergency (PHE) for COVID-19 ending?	Yes. On January 30, 2023, the Biden administration announced that the PHE for COVID-19 is ending on May 11, 2023. This gives the government and others impacted 90 days to wind down current mandates set under the PHE.
What is a public health emergency?	With the declaration of a public health emergency, the federal government is allowed to access funding to prevent, prepare for, and respond to a disease emergency. It waives certain requirements and allows for new mandates to be established in response to the emergency.
What does the end of the public health emergency mean?	The end of the PHE means that most of the mandates under the current PHE for COVID-19 end on May 11, 2023. This could result in a loss of coverage for some people, or increased costs associated with COVID-19 for others.
Will I have to pay for COVID-19 vaccines and boosters now?	COVID-19 vaccinations will be free for those with insurance even when the PHE ends because of various federal laws, including the Affordable Care Act and pandemic-era measures, the Inflation Reduction Act, and a 2020 relief package. Vaccinations will continue to be free for those with private insurance who go to in-network providers; going to an out-of-network provider could mean out-of-pocket charges.
What about the cost of vaccines?	While vaccinations will continue to be free for most members, the cost to insurers (and self-funded employers) will increase. Under the PHE, only the cost of administering the vaccine was allowed to be billed. This was typically around $25 per shot. With the end of the PHE, the federal government will no longer buy COVID-19 vaccines. The cost of the vaccines will now revert to commercial prices, which could range from $82 to $130 per dose. This cost would be borne by self-funded employer groups and health insurers.
Will the cost of COVID-19 treatments continue to be at no cost?	Those with private insurance have not been charged for monoclonal antibody treatment since they were prepaid by the federal government, though patients may be charged for the office visit or administration of the treatment. But that is not tied to the public health emergency, and the free treatments will be available until the federal supply is exhausted. The government has already run out of some of the treatments so those with private insurance may already be picking up some of the cost. We don’t know what the commercial price will be for monoclonal antibody treatments.
Can I still get free at-home COVID-19 tests?	Under the PHE, people could get up to 8 at-home COVID-19 tests per month. That ends on May 11, 2023, meaning any at-home tests after that time will be at cost for the member.
What can I expect as a self-funded employer?	The end of the PHE means that the federal government is no longer purchasing COVID-19 vaccines for the public. Also, monoclonal antibody treatment supply, also purchased by the federal government, is running low. That means that public (commercial) pricing will now apply for vaccines and treatments. We don’t yet know the actual commercial price but have seen reports indicating a cost between $82 to $130 per shot. We don’t yet know of any commercial pricing for treatments.
How is LifeWise handling all the pieces that must be undone?	We’re currently developing our internal wind-down plan to ensure that all policies, claims processes, coding, and programs are ending or continuing as mandated. We’ll keep you posted as we learn more about the elements that will continue, the wind-down process, and pricing.

COVID-19 and waivers

Is COVID-19 testing covered?

The new Families First Coronavirus Response Act requires all group health plans, including self-funded plans, to provide coverage for diagnostic testing, including U.S. Food and Drug Administration (FDA)-approved COVID-19 diagnostic testing products and items and services related to testing furnished during an office, telehealth, urgent care center or emergency room visit. We have removed the group waivers that were previously in place to comply with this mandate.

LifeWise follows state and federal mandates related to end dates for these services. See COVID-19 Key Dates section in this FAQ for current dates.

Commercial and Medicare Supplement Members: We're waiving in-network cost shares (coinsurance, copays, and deductibles) for members requiring FDA-authorized diagnostic COVID-19 and influenza testing. Per WA OIC Washington state Office of the Insurance Commissioner (OIC) requirements, we're also waiving in-network copays, cost shares, and deductibles for other virus/respiratory testing tied to a COVID-19 diagnosis. All other treatments and services including hospitalization not related to a COVID-19 diagnosis will be subject to the usual benefits and cost shares. The waivers apply for testing and the related provider visit at in- and out-of-network facilities and laboratories.

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How will President Biden’s plan for insurers to cover self-tests impact current coverage?

President Joe Biden laid out his strategy to fight the Omicron and Delta coronavirus variants over the winter, which included insurer-funded at-home COVID-19 testing. The rules regarding health plan reimbursement for self-tests purchased by consumers were made available on January 10, 2022.This mandate applies to all commercial plans.

Eligible tests are those with full FDA or EUA authorization and designated as home tests (antigen or molecular approved tests) used for diagnostic purposes (e.g., symptoms or direct exposure). Tests for surveillance purposes such as work or travel continue to be not covered. We will apply the quantity limit of 8 individual tests (not package) per covered member per 30 rolling days. These tests are not available for members with Medicare plans.

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Is return-to-work/return-to-school testing covered and how do I bill for it? What about personal or work-related travel?

LifeWise is not required under either state or federal law to provide coverage for return-to--work testing or occupational testing. We will not cover testing for occupational or accommodation purposes when an employee has an approved vaccine mandate accommodation from their employer. LifeWise also doesn’t cover return to school or any travel related testing. Federal and state law do not require that these tests be reimbursed as part of a health plan.

Tests done for return to work or school, travel, or purposes other than diagnosing when a patient has symptoms or exposure, may not be coded as diagnostic and may not be billed to the plan. These tests are strictly member liability.

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Are serology tests covered?

Our Benefit Coverage Guideline is effective for serology tests for dates of service July 1, 2020 and forward. LifeWise will reimburse for serology tests that are for the purpose of supporting a COVID-19 diagnosis as part of the treatment or management of a patient's medical condition. Serology tests provided on an inpatient basis are presumed to be for diagnostic purposes. Tests performed on an outpatient basis require records confirming that the test is for the diagnosis of the disease or condition of a patient.

The Benefit Coverage Guideline follows CDC guidance on scenarios in which serological tests will not be covered when provided as the sole basis of diagnosis for current infection with COVID-19.

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Is COVID-19 treatment covered and are there any limitations?

While cost share waivers including copays, deductibles, and coinsurance for all COVID-19 related treatment (both inpatient and outpatient) ended on June 30, 2021, treatment costs are still covered as a medical expense.  Cost share waivers for COVID-19 diagnostic testing and related provider visit remains in place.

See the COVID-19 Key Dates section in this FAQ for current dates.

You can check eligibility and benefits on our website.

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Are there specific codes for COVID-19?

The following summary of coding instruction is provided by the CDC, WHO, and CMS related to COVID-19. We urge you to use this COVID-19 coding for patients so cost shares may be waived appropriately

There are two new HCPCS codes for lab tests to detect COVID-19:

1. Code for U0001 for the Centers for Disease Control (CDC) test panel
2. Code U0002 for other tests

In addition, two additional COVID test HCPCS codes U0003/U0004 for high throughput technologies are covered.

The American Medical Association added a new CPT code for reporting the novel coronavirus tests:
87635: Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique.

Per the CDC, a new ICD-10 emergency code, U07.1, 2019-nCoV acute respiratory disease, has been established by the WHO for reporting the virus, effective with the next update, October 1, 2020. LifeWise is accepting this code and encourages you to use it.

To identify patients in the interim who have tested positive for COVID-19, current CDC guidance instructs to code first for the presenting illness followed by B97.29 - Other coronavirus, as the cause of diseases classified elsewhere.

For the new serology (antibody) tests, the AMA created new CPT lab test codes: 86328 and 86769. Use these codes when submitting a claim for the antibody test.

As of January 1, 2021, new specific diagnosis codes must be used for all claims related to COVID-19 testing, treatment, and vaccines.

You can learn more about the codes through the following Centers for Disease Control (CDC) resources:

• CDC: New COVID-19 ICD-10 Codes Effective January 1, 2021
  One-page announcement of further additions to ICD-10 codes.
• CDC: New COVID-19 Official Coding Guidelines
  Chapter-specific coding guidelines, pages 28-33.

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Are physician oversight fees from labs covered as part of the testing?

Some lab companies are charging members a $10 non-refundable service fee for "physician oversight services" when a member orders testing directly through a lab. The $10 fee is for an independent physician who orders test for the member. The member also has the option to consult with this physician to discuss their results. This fee is not submitted to insurance for reimbursement by the lab service or the physician. This type of service fee and claim are not covered by the medical plan. To avoid this type of service fee, members should use their own provider or clinic when requesting COVID-19 testing.

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Are home testing kits, including the ones I get at the pharmacy, covered?

FDA-authorized COVID-19 home test kits are only covered when ordered by a licensed physician or pharmacist, or when purchased by a member for use when a person has COVID-19 symptoms or has had direct exposure. Home test kits will be not be covered if used for non-diagnostic purposes (i.e., travel, return to work, etc.). Members may submit claims for reimbursement for in-home tests using the OTC claim reimbursement form. A separate claim reimbursement form is required if reimbursement is needed on more than one covered family member. The test you purchase must have been granted full or Emergency Use Authorization (EUA) by the Food & Drug Administration (FDA) and labeled for home use and have been purchased January 15, 2022 or later. Check the EUA list for approved home tests.

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COVID-19 vaccines

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Is a booster COVID-19 vaccine dose approved?

New bivalent boosters are available from Moderna and Pfizer. The current monovalent boosters should only be used in children who are too young to receive one of the bivalent boosters.

• A Pfizer-BioNTech monovalent vaccine is authorized for children 6 months-11 years and a Moderna vaccine was authorized for children 6 months-17 years.
• Children need a 3-dose Pfizer primary series or a 2-dose Moderna primary series.
• A new Moderna bivalent booster vaccine dose was authorized for people ages 6 months and up. New codes apply. 
• A new Novavax booster vaccine dose was authorized for people ages 18 and older. New codes apply.

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What vaccines are available?

Pfizer-BioNTech vaccines are available to people ages 6 months and up. A Moderna vaccine is available for people ages 6 months and up. A Moderna booster vaccine dose was authorized for youth ages 6-17. This is in addition to the Pfizer booster dose already authorized for children 5-17.

The Novovax vaccine was given EUA approval on July 20, 2022 for people ages 18 and up. It’s a 2-dose series given 3 weeks apart. It’s similar to the same protein base used in flu shots, instead of the mRNA base used in the Pfizer and Moderna vaccines.

• Janssen COVID-19 vaccine is only recommended for certain individuals. Read the information provided by the CDC regarding appropriate use of the Janssen vaccine.
• Health plans will continue to cover all vaccine administrative costs for their members as required, while Centers for Medicare & Medicaid Services (CMS) said Medicare will reimburse providers for vaccines through the current PHE.
• Correct coding is required to process your claim. Claims that are incorrectly coded may be rejected. The correct codes are noted in the coding section below.

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Are these vaccines available for children?

The Pfizer pediatric dose of the COVID-19 vaccine was approved on November 2, 2021, for children ages 5 to 11. Moderna and Johnson & Johnson are for those age 18 and up.

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What if the child turns 12 between the first and second dose?

If your child turns 12 between the first and second doses of the vaccine, the CDC is recommending they receive the full regular dose for their second shot.

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I have a patient with long COVID-19. Are there codes to use for these symptoms?

As a result of the ongoing COVID-19 public health emergency, the Centers for Disease Control and Prevention’s National Center for Health Statistics (CDC/NCHS) has implemented an additional code, U09.9 - post COVID-19 condition, unspecified.

This code became effective October 1, 2021, to identify conditions following acute COVID-19. It's a secondary diagnosis code added after the specific condition related to COVID-19 is known, such as chronic respiratory failure, loss of smell, loss of taste, multisystem inflammatory syndrome, pulmonary embolism, pulmonary fibrosis etc. This code is not used in cases that are still presenting with active COVID-19 but it conditions which are the consequence of COVID-19.

View CDC's ICD-10-CM coding guidance.

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What about the single dose Johnson & Johnson vaccine?

• Janssen COVID-19 Vaccine is authorized for adults ages 18 years and older in certain limited situations due to safety considerations. For guidance on respective record review, scheduling and administration of Janssen vaccine see Interim Clinical Considerations for Use of COVID-19 Vaccines: Appendices, References, and Previous Updates | CDC

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Will this be my last booster?

Currently unknown. Some scientists think eventually people may get regular COVID-19 shots like annual flu vaccinations. But researchers will need to study how long protection from the current boosters lasts.

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Should I recommend my patients get a flu shot?

The CDC, and many medical practitioners, are strongly recommending everyone get a flu shot this year. With the flu almost non-existent last year due to the stay-at-home orders, masking and handwashing, many are expecting this flu season to come back strongly. According to the CDC, it is safe to get both your COVID-19 vaccine and the flu vaccine at the same time.

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Can I bill for vaccine counseling?

Executive Order 21-02 allows for billing for COVID vaccine counseling when provided to your patients. These are the requirements for a claim to be submitted and paid for claims with dates of service beginning June 25, 2021. See the end date grid for dates.

• This order is for Washington members only on fully insured plans and SEBB members and only for COVID-19 vaccine counseling. You can check a patient’s plan status by using the Eligibility & Benefits tool on the LifeWise provider website.
• Check a patient’s vaccination status in the provider’s medical records and the Washington State Immunization Information System (WAIIS) database. Contact only those patients that haven’t been fully vaccinated or haven’t started vaccinations;
• You must have an established relationship with the patient that includes at least one in-person appointment within the past three years with you or another provider at the same clinic;
• You or your staff must do the outreach; 
• You may use video, phone, or in-person. Text messages, email or voicemail aren’t covered under this order;
• In order for cost shares to be waived, you must use correct coding when submitting the claim. This includes the correct diagnosis and CPT codes. Fees are based on your current contracted rates:
  • CPT Code 99401 – in-person consultation and available for audio and visual telehealth visits
  • CPT Code 99441 – audio only (telephone) counseling for physicians
  • CPT Code 98966 – audio only (telephone) counseling for non-physicians (Medical Assistants, Nurses, etc.)
  • Diagnosis code Z71.89 in the primary position must be included for the claim to process correctly 
  • If you’re billing for vaccine counseling during a regular office visit, you must append modifier 25 to the counseling procedure code so both the Office Visit and the counseling procedure codes will be paid appropriately.
• There is a limit of two claims per patient per provider.

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Do providers and pharmacies need to do anything to be able to administer the COVID vaccine?

Yes. If you want to enroll in your state Medicaid program, reach out to your representative from the State Medicaid Agency Provider Enrollment Contact List (PDF).

For commercial plans, to receive/administer COVID-19 vaccine, constituent products, and ancillary supplies, vaccination provider facilities/organizations must enroll in the federal COVID-19 Vaccination Program coordinated through their jurisdiction's immunization program. Enrolled COVID-19 vaccination providers must be credentialed/licensed in the jurisdiction where vaccination takes place, and sign and agree to the conditions in the CDC COVID-19 Vaccination Program Provider Agreement. These conditions are detailed in the agreement itself.

In Washington, to receive and administer the COVID-19 vaccine, providers have to enroll in a federal vaccine distribution program, coordinated through the state immunization program (unless they are part of a national chain registered directly with the CDC [eg, major retail pharmacy chains). Washington state providers can enroll as COVID-19 vaccine providers.

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Specific codes must be used for the Pfizer, Moderna, and Johnson & Johnson vaccines. Use the links below to ensure the new codes are in your system to facilitate efficient claims processing.

COVID-19 Vaccine codes (medical)
Primary vaccines

Booster doses

Bivalent booster doses

Get the most up to date list of billing codes, payment allowances and effective dates.

Dental COVID-19 codes (Lab tests only)

ADA Code	ADA Code Description
D0606	Molecular testing for a public health related pathogen, including coronavirus

Get the most up to date list of billing codes, payment allowances and effective dates.

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Who can I contact if I'm a pharmacy having difficulty billing for the vaccine?

If you are having difficulty billing for the COVID vaccine, you can contact the Express Scripts help desk at 800-922-1557.

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Where can I get more information about the vaccines?

Information about vaccines and distribution will continue to evolve.

For general questions about COVID-19 vaccines and vaccine trials, and for the CDC playbook:

Centers for Medicare and Medicaid Services (CMS)
Centers for Disease Control and Prevention (CDC)

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How much will it cost?

The federal government has mandated that the cost of the vaccine will be $0 for everyone in the U.S. The cost for administering the vaccine will be covered by insurance, for those with coverage, or waived for those without coverage. Providers may bill an insurance company for administrative costs.

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How will the vaccine be billed?

The cost of the actual vaccine is being covered by the government currently. The cost of administering the vaccine will be covered by insurers, like LifeWise. CMS has recently released expected costs for vaccine administration. We expect the vaccines will be billed by dose, similar to how other 2-dose vaccines are billed.

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Do I need a doctor's referral or prescription?

Check with your state to determine what identification or referral may be required for each phase.

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Are these vaccines available for children?
The Pfizer-BioNTech COVID-19 vaccine is available for adolescents aged 12 to 15. Moderna is approved for those 18 and older. Studies to test COVID-19 vaccines are beginning for those under the age of 12.

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Am I required to get the COVID-19 vaccine?

There may be requirements for you to be fully vaccinated. Check with your local government or employer for information.

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Virtual care

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Are you expanding telehealth behavioral health and substance use disorder access during the COVID-19 health crisis?

In addition to our existing LifeWise contracted behavioral health providers (Talkspace, brick-and-mortar providers, and Employer Assistance Programs), virtual access for behavioral health and substance use disorder treatment (opioid and alcohol) may include access to the expanded telehealth network, depending on the member's benefit plan design:

• Doctor on Demand – Doctor on Demand was added to our telehealth network. These services are available to member adults and children in all states.
• Boulder Care - Boulder Care is a digital care provider, offering long-term support and medication-based treatment for opioid use disorder (OUD) and common co-occurring conditions for members 18 years and older. Their digital platform allows patients to connect with providers 24/7 through secure video and messaging with clinicians, care advocates, and peer coaches. Boulder Care is working towards 50 states licensure. If they aren't licensed in a certain state they will transition the member to an in-network provider for the appropriate services.
• Workit Health – Workit is a digital care provider offering support for alcohol use disorder (AUD). Via Workit web and phone apps, members age 18 and older have a "recovery in their pocket" harm reduction and sobriety solution that provides 24/7 access to interactive therapeutic courses, online support groups supervised by licensed care teams. Workit is working towards 50 states licensure. If they aren't licensed in a certain state, they will transition the member to an in-network provider for the appropriate services.

Additional covered telehealth services include:

• Applied behavioral analysis (ABA)
• Partial hospitalization programs (PHP) for mental health and substance use disorders
• Intensive outpatient programs (IOP) for mental health and substance use disorders

Doctor on Demand, 98point6, Boulder Care, and WorkIt Health are independent companies that provide virtual medical care services on behalf of LifeWise.

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Are there resources for people that are dealing with a mental health issue?

Yes. LifeWise offers Talkspace for all our members. This is an online, virtual behavioral health provider resource. Many local mental health providers are also offering virtual services. Your patient should check with their provider first, or they can go directly to Talkspace at Talkspace.com/LifeWise

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Can I offer telehealth services to my patients?

Yes. Virtual care is covered under the scope of your current contract with LifeWise, if the care provided is appropriate within the scope of the provider's licensure. This change applies to LifeWise individual and commercial members. However, some self-funded employer groups do not cover virtual care, so you'll need to check benefits for your patient before providing care

Note: Telehealth services aren't coded like in-office visits due to different modifiers and Place of Service codes needed to identify a telehealth service. There are additional codes that can be used for online video encounters as well as telephone visits in conjunction with the office visit codes.

For LifeWise-contracted providers, your current contract covers telehealth services if the care provided is appropriate within the scope of the provider's licensure. Note: Telehealth services aren't coded like in-office visits. Refer to your LifeWise contract for allowable information for virtual care codes. For specific coding information for LifeWise patients, see our telehealth payment policy for Washington.

For dental providers, you may bill the following visit types via tele-dentistry adding tele-dentistry modifier code of D9995/6:

• D0140 - Limited Oral Evaluation – Problem Focused
• D0170 - Re-evaluation, limited problem focused (established patient, not post-operative visit): This code is appropriate when assessing a previously existing condition related to trauma, or a follow-up evaluation for continuing issues
• D0190 – Screening of a patient. A screening, including state or federally mandated screenings, to determine an individual's need to be seen by a dentist for a diagnosis.
• This temporary modification becomes policy on April 1, 2021.

LifeWise wants to emphasize that this is a temporary relaxation of the rules during this nationwide public health emergency. Correct coding and notification to the patient that the provider is using non-HIPAA compliant communication tools is required

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Are there specific telehealth codes?

For providers who are delivering services via telehealth, LifeWise will require providers to continue use the correct telehealth place of service (POS) 02 with the procedure code appended with either modifier 95 or GT. Claims with modifiers indicating they were telehealth, if billed with POS 11, will be rejected up front and will require the correct POS to match the service billed. We will no longer accept POS 11 for telehealth services.

This guidance is in effect for WA group plans, FEP and Individual plans. Shared Admin are excluded from this guidance.

Refer to your LifeWise contract for allowable information for virtual care codes. For specific coding information for LifeWise patients, see our telehealth payment policy for Washington.

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What about HIPAA rules?

Per Health & Human Services and the Office of Civil Rights, a covered physician or health care provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients. OCR is exercising its enforcement discretion to not impose penalties for noncompliance with the HIPAA rules in connection with the good faith provision of telehealth using such non-public facing audio or video communication products during the COVID-19 nationwide public health emergency. This exercise of discretion applies to telehealth provided for any reason, regardless of whether the telehealth service is related to the diagnosis and treatment of health conditions related to COVID-19. Additionally, the criteria that telehealth may only be used with established patients is being relaxed and new patient encounters can be billed with these codes.

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Can I see new patients using telehealth?

Providers can care for new patients via a telehealth virtual encounter and bill those services using the appropriate CPT code for the services rendered, in addition to the telehealth modifier and place of service. Virtual care for an established patient should also be billed with an appropriate CPT code, many of which are found in our payment policy. Note that these services must also be billed using the appropriate telehealth modifier and place of service.

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Can ABA services be provided virtually?

Yes, ABA services can be provided virtually for dates of service on or after March 20, 2020. This is temporary and is in effect until government agencies indicate that we no longer need to practice social distancing.

Claims for services provided virtually must be submitted with appropriate telehealth modifiers using the codes currently on the ABA fee schedule (see telehealth payment policy).

Reimbursement for virtual care will be at the same amount as if the service were provided in-person.

This change applies to our individual and commercial members.

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How do I capture a physical exam if I'm not physically present with the patient?

With the increasing use of telemedicine to interact and treat patients, it can be difficult to capture information and do a physical exam. Fortunately, synchronous audio and video platforms make it possible for providers to capture almost all areas of a physical exam. We've developed a tip sheet using best practices and information from Telemedicine: Conducting an Effective Physical Exam to help you conduct an effective physical exam during a telehealth visit.

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Pharmacy and prescriptions

Can patients refill prescriptions early if needed?

90-day refills:
Most plans have access to mail-order prescriptions. Ask your provider about getting a 90-day supply.

Note: Some prescriptions aren’t eligible for mail order. Members should check their plan benefits or contact customer service at the number on the back of their ID card.

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How is LifeWise covering the drugs used to treat COVID-19?

Drugs that have received Emergency Use Authorization (EUA) or full FDA approval for the treatment of COVID will be covered under current policies and according to your health plan benefits.

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Prior authorizations

Is LifeWise extending prior authorization timeframes?

The OIC's second emergency order required we waive or expedite prior authorization requirements for home health care or long-term care facility services. See COVID-19 Key Dates section in this FAQ for current dates.