The federal Public Health Emergency (PHE) for COVID-19 is expiring at the end of the day on May 11, 2023, and many states have previously lifted their state of emergency, as well. As a result, Point32Health, the parent company of Harvard Pilgrim Health Care and Tufts Health Plan, is returning to many pre-pandemic operations and policies. Please refer to the information below for details on our COVID-19 related policies and practices, effective May 12, 2023.
Point32Health complies with federal and state guidelines for vaccines, including boosters.
COVID-19 vaccines administered by in-network providers will remain covered at no cost to our members. We are following federal and state guidance related to member cost shares for out-of-network COVID-19 vaccines as follows:
- MA: Remain covered with no member cost-share
- ME, NH and RI: Covered at no member cost share only when in-network vaccines are unavailable
- Self-Insured: Self-Insured plans may apply different member cost-sharing. Please contact your employer.
Provider reimbursement for COVID-19 vaccines: Point32Health reimburses providers for the administration of COVID vaccines and associated services. The reimbursement rate includes vaccine administration, public health reporting, and patient outreach, education, and counseling. Please refer to the COVID-19 Vaccine and Testing Codes list (for Harvard Pilgrim; for Tufts Health Plan) for billing information to ensure claims are processed appropriately.
COVID testing and treatment
- Testing for COVID-19 infection is covered when ordered or referred by a physician or appropriately licensed health care provider, or in accordance with state regulatory guidelines. In order to be considered medically necessary, COVID-19 antibody testing must be ordered by the member’s treatment physician or appropriately licenses care professional, the test must be FDA approved or have FDA emergency use authorization, and the test must be necessary to make decisions required to treat a members’ immediate medical condition. Tests are not covered if conducted solely for return-to-work or return-to-school purposes, for public health surveillance, or for any other purpose not primarily intended for individualized diagnosis or treatment, except when required by state regulatory guidelines.
- Over-the-counter/home testing kits: On May 12, 2023, following the end of the federal public health emergency, we will no longer cover over-the-counter COVID-19 tests for our Commercial members. Our Medicare members will also no longer have coverage through their Red, White and Blue Medicare card. Our Medicaid (including Tufts Health One Care and Tufts Health Plan SCO) members will continue to have access, based on MassHealth and Rhode Island Medicaid requirements.
- Provider Ordered Testing and Treatment: COVID-19 tests, treatments and services ordered by a provider, including Paxlovid, will remain covered and we follow federal guidelines regarding approved treatments. We are following state guidance related to member cost shares for these services. Vaccines remain covered, member cost share may vary by product and state.
- Point32Health covers in-person polymerase chain reaction (PCR), antigen and antibody laboratory testing for COVID-19 consistent with federal and state guidance. For complete information, please refer to the COVID-19 Antibody (serological) testing policy (Harvard Pilgrim version; Tufts Health Plan version)
- Members are encouraged to use participating providers/laboratories for all COVID-19 testing.
- Please refer to our Medical Necessity Guidelines for COVID-19 Monoclonal Antibody Therapy for guidance on monoclonal antibody therapy (Harvard Pilgrim version; Tufts Health Plan version)
Referral and prior authorization guidelines
- Members of Massachusetts Commercial plans and Tufts Health Direct: Harvard Pilgrim and Tufts Health Plan continue to waive prior authorization requirements for in-network and OON providers when related to a COVID-19 diagnosis in accordance with Massachusetts Division of Insurance Bulletin 2021-08.
- Tufts Health Together, Tufts Health One Care and Tufts Health Plan SCO: In accordance with MassHealth Managed Care Entity Bulletin 22 and until further notice, managed care plans must not impose any referral requirements for any medically necessary covered services.
- For all other states and products: Prior authorization requirements apply where applicable and pre-COVID processes should be followed.