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Ambetter Member Plan Benefits Resume for Applicable COVID-19 Testing, Screening, and Vaccination Services as of August 1, 2023

Date: 08/01/23

Since the federal Public Health Emergency (PHE) related to the COVID-19 pandemic ended on May 11, 2023, Ambetter is committed to providing a smooth transition for both our members and providers as we resume business as usual. During the PHE, Ambetter followed guidance from Centers for Medicaid and Medicare (CMS) and instituted temporary waivers for select services to ensure critical care could be quickly delivered to our members during a time of heightened need. Beginning August 1, 2023, these temporary waivers will expire, and our members’ plan benefits will be reinstated for the following services:


Member Liability

Prior Auth Needed?

COVID-19 Testing and Screening

(Administered by Provider)

Per member plan benefits


COVID-19 Vaccinations

In-Network: $0 member cost share

Out-of-Network: Per member plan benefits


COVID-19 Over-the-Counter Tests

Not covered


Alongside these waivers, the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided for a 20% increase to the inpatient prospective payment system (IPPS) Diagnosis Related Group (DRG) rate for COVID-19 patients for the duration of the public health emergency. This increase applied to claims that included the applicable COVID-19 ICD-10-CM diagnosis code and met the date of service requirement. Per the PHE sunset on May 11, 2023, these add-on payments are no longer included for discharge dates of service 5/12/2023 and after.

Current telehealth coverages are not affected by the ending of the PHE, and will remain through 12/31/24 per the Consolidations Appropriations Act of 2023.

While we will continue to communicate any updates to our business practices directly to our provider partners, we always highly recommend that providers verify member eligibility, benefits, and prior authorization requirements before rendering services.