APhA coronavirus watch: New York, Ohio, and Maryland make moves toward allowing pharmacists to bill Medicaid for COVID-19 testing

[UPDATE: Maryland has also taken steps to allow pharmacists to bill Medicaid for specimen collection. More to come.]

The U.S. Department of Health and Human Services (HHS) has made clear that federal orders allowing pharmacists to order and administer FDA-authorized COVID-19 tests supersede state limits on scope of practice, and in at least one case has instructed a state pharmacy association to stop preventing pharmacists from testing for COVID-19. Now states are taking the baton, making widespread testing a possibility by creating pathways for pharmacists to bill for these services. Lack of avenues for payment has been a major barrier to increased access to COVID-19 testing at pharmacies.

Big steps in the Empire State

New York Gov. Andrew Cuomo issued an executive order on May 22 that authorized licensed pharmacists to order COVID-19 tests approved by FDA through emergency use authorizations detect SARS-CoV-2 or its antibodies; administer COVID-19 tests subject to CLIA certificate of waiver in patients suspected of a COVID-19 infection, or suspected of having recovered from COVID-19 infection, subject to completion of appropriate training developed by the New York Department of Health; and be designated as qualified health care professionals for the purpose of directing a limited service laboratory to test patients for COVID-19 infection or its antibodies. These mandates, to remain in place through the duration of New York’s emergency declaration, are consistent with HHS guidance.

Cuomo’s order also states that pharmacies may bill New York’s Medicaid fee-for-service program for either COVID-19 specimen collection or CLIA-waived COVID-19 tests. Tests for dual eligibles—those enrolled in both Medicaid and Medicare—will continue to be billed to Medicare, not Medicaid. The executive order includes billing codes and values.

The state’s Medicaid managed care program will provide separate guidance on billing for COVID-19 testing.

New York pharmacies that perform and bill Medicaid for COVID-19 testing cannot bill for specimen collection, as reimbursement will include both specimen collection and the generation of a lab report. Pharmacies that are already paid for testing by a source other than Medicaid will not be allowed to bill Medicaid on top of that.

Ohio inches toward payment

On May 28, Ohio Gov. Mike DeWine announced new Ohio Board of Pharmacy rules that allow pharmacists to order and administer coronavirus tests. Ohio is one of several states to empower pharmacies to provide COVID-19 testing or specimen collection.

But, unlike many other states, DeWine indicated to the Ohio Pharmacy Association (OPA) that he will instruct Ohio’s Medicaid program to create codes that allow pharmacies to bill for tests on program beneficiaries.

The new Ohio rule changes instituted by the DeWine administration align with HHS guidance on pharmacist-initiated testing and eliminate regulatory hurdles that previously stood in the way of pharmacists seamlessly ordering and administering COVID-19 testing, said Antonio Ciaccia, OPA director of government and public affairs.

“[OPA] spoke at length with Gov. DeWine about both the legal and economic barriers that stood in the way of pharmacist-initiated COVID-19 testing. He very much understood that if the state wants to expand access to COVID-19 testing at pharmacies, that adequate incentives must be created to make that happen,” Ciaccia said. In recognition of the value of pharmacists in increasing access to testing and other services, “[DeWine] has committed to working to ensure that there is a financially viable pathway for pharmacists to conduct testing for Medicaid beneficiaries.”

It's unclear exactly when pharmacists will be able to begin billing for tests on Medicaid patients, but it could lead to coverage by other payers, Ciaccia said. “Often, Medicaid and Medicare policies lead the way for policies with private payers. In Ohio, Gov. DeWine has been dedicated to expanding patient access to testing, and we are confident that once Medicaid gets pharmacist-initiated testing up and running, other commercial payers will begin including coverage as well.”

The cooperation of private insurers in achieving the state’s goals to rapidly increase access to COVID-19 testing is crucial to restoring normalcy and reinvigorating the economy, he added.

What this does and doesn’t mean

In Ohio, “the reality is that the Medicaid program still has to figure out how to implement [DeWine’s orders],” said Rebecca P. Snead, executive vice president and CEO of the National Alliance of State Pharmacy Associations. “The New York order includes billing instructions that tell [pharmacists] exactly what they need to do and how much they’ll get paid. Ohio hasn’t gone through that process as of yesterday. I think it’s imminent, but right now it’s just ‘the governor instructed Medicaid to pay pharmacists for this’—which is amazing—but not ‘Medicaid is going to pay Ohio pharmacists for this.’”

HHS has sent a strong signal to states that they need to remove any barriers to pharmacists being able to order and conduct these tests, but the agency’s guidance said nothing about payment for the tests themselves or for pharmacists’ services—or who would pay them, Snead said. “But it’s reasonable to link the fact that you can’t expect anyone to do these tests without paying them for doing it.”

Private insurers have committed to making tests available at no cost to beneficiaries. “But that doesn’t mean that any provider—pharmacists or anybody else—will actually get paid for administering the test,” Snead said. “That fact that patients won’t be charged for the test is huge, and it’s a good soundbite, but it doesn’t really mean anything [to health care providers].”

Ciaccia is encouraged by state action but also wary of the federal government’s lack of explicit intention to pay COVID-19 testers. “Other governors across the country are turning to pharmacists as a necessary component of combatting this pandemic,” he said. “President Trump and CMS should follow the lead of our state leaders on the ground to ensure our nation’s seniors have the same access and standard of care as our Medicaid beneficiaries.”