What EmblemHealth’s Medicare Advantage and some Commercial providers need to know about the CARES Act

EmblemHealth will follow Medicare guidelines in the federal coronavirus (COVID-19) stimulus bill (known as the “CARES Act”) to:

  • Add 20% to the COVID-19 inpatient reimbursement for both in-network and out-of-network care given to Medicare Advantage members and certain in-network Commercial members
  • Temporarily suspend the 2% provider payment reduction fee known as “Medicare sequestration” from May 1, 2020 through Dec. 31, 2020.


Adding 20% to COVID-19 inpatient reimbursement

In accordance with Centers for Medicare & Medicaid Services (CMS) methodology, EmblemHealth will add 20% to the MS-DRG-based inpatient reimbursement (operating component only) for Medicare Advantage patients who were discharged with a COVID-19 diagnosis after Jan. 27, 2020. In addition, for care given to in-network Commercial members for which contractual payment is based on Centers for Medicare & Medicaid Services (CMS) inpatient prospective payment system (IPPS), the applicable inpatient reimbursement will be increased by 20%. EmblemHealth will adjust all previously processed claims. Providers do not need to resubmit the claims. Providers must follow the coding and billing requirements from the CMS. This will apply to both in-network and out-of-network providers.

  • For in-network providers, the increase will be applied, as appropriate, to payments to providers whose contracted reimbursement is based on the CMS inpatient prospective payment system.
  • For out-of-network providers, the increase will be applied only for Medicare Advantage members based on CMS requirements.


Temporary suspension of the Medicare sequestration fee

We will temporarily suspend the 2% Medicare sequestration fee for in-network providers based on the terms of your participation agreement with EmblemHealth. This temporary suspension applies to payments with dates of services or discharges from May 1, 2020 through Dec. 31, 2020.