During the federal COVID-19 public health emergency (PHE), the Benefit Funds temporarily changed specific policies to ensure that your 1199SEIU patients had access to medical services during that challenging time.
Following the recent expiration of the PHE declaration by the Secretary of the Department of Health and Human Services under Section 319 of the Public Health Service Act, the Benefit Funds are reinstating suspended member cost sharing for COVID-19-related visits and diagnostic services. In addition, the Benefit Funds are continuing to cover certain communication technology-based services and telehealth services, as set forth in more detail below.
Reinstating the Member Cost Share
As of January 1, 2024, the Benefit Funds’ reimbursement for the following services will be reduced by the applicable co-pay amounts:
- Home Care Benefit Fund Plan B Network members: $5/$10 co-pays for office visits (PCPs/specialists), $25 inpatient co-pay
- Greater New York Benefit Fund members: $75 co-pay for emergency room visits
Please review your patients’ Health Benefits ID cards for applicable co-pays.
Continuing Coverage of Certain Communication Technology-Based Services/Telehealth Services
The Benefit Funds will continue to cover technology-based/telehealth services based on the Benefit Funds’ telehealth policy, which considers the following:
- Setting and place of service necessary for service
- Provider type and specialty
- Appropriateness of CPT vs. HCPCS codes
- CMS’ expanded coverage rules and guidelines
- Other relevant Benefit Funds coverage determination and policies
The following communication technology-based services/telehealth services continue to remain non-covered by the Funds:
- Services performed in a setting that is not covered by the Benefit Funds, such as nursing facilities, domiciliary and rest homes
- In-person contact
- On-site settings, such as inpatient, bedside and in-facility services
- Services provided at urgent care centers
