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Agency FAQs Address Group Health Plans and COVID-19

07.20.2020

The Department of Labor, IRS and Department of Health and Human Services (HHS) recently issued frequently asked questions (FAQs) addressing the impact on group health plans of legislation passed in response to the novel coronavirus (COVID-19) pandemic. The laws in question are the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES) Act.

The FFCRA generally requires group health plans and insurers to cover (without cost-sharing, prior authorization or other medical management requirements) certain items and services related to diagnostic testing for COVID-19. The CARES Act requires coverage of a broader range of diagnostic items and services. It generally requires plans and insurers to reimburse any provider of diagnostic tests the publicly listed cash price or a lower negotiated rate. Here are some highlights from the agency FAQs.

Diagnostic tests

Plans and insurers must cover in vitro diagnostic tests (and the administration of tests) that are:

  • Approved, cleared or authorized by the Food and Drug Administration (FDA),
  • Subject to a developer’s request (or intended request) for FDA emergency use authorization,
  • Developed in and authorized by a state, or
  • Determined appropriate by the HHS.

Serological tests to determine antibodies for COVID-19 are considered diagnostic tests and must be covered if they otherwise meet the requirements. States may impose additional requirements on insurers with respect to the diagnosis or treatment of COVID-19, so long as the requirements don’t prevent the application of the federal requirements.

Office visits and other services

Coverage is mandated for items and services furnished during health care provider office visits — including in-person and telehealth visits, as well as drive-through screening and testing visits. Coverage is also mandated for urgent care center visits and emergency room visits that result in an order for or administration of a diagnostic test. However, the mandate applies only to the extent the items and services relate to the furnishing or administration of a COVID-19 test or the evaluation of the individual for purposes of determining the need for the test.

For example, say an individual’s provider determines that influenza tests or blood tests should be performed during a visit to determine an individual’s need for a diagnostic test for COVID-19. The visit results in an order for, or the administration of, a diagnostic test. In such an instance, the plan or insurer must provide coverage for the related tests without cost-sharing, prior authorization or other medical management requirements. Plans and insurers are required to provide coverage for items and services furnished by both in-network and out-of-network providers.

EAPs and on-site clinic benefits

An employee assistance program (EAP) is considered an excepted benefit only if, among other requirements, the EAP doesn’t provide significant benefits in the nature of medical care. An EAP won’t be considered to provide benefits that are “significant in the nature of medical care” solely because it covers diagnostic tests while a COVID-19 federal emergency health declaration is in effect. In addition, an employer’s on-site medical clinic can cover diagnostic tests without losing its excepted benefit status.

SBC and plan modifications

Agencies won’t take enforcement action against plans or insurers that adopt modifications to provide greater coverage for COVID-19 diagnosis or treatment without providing the minimum 60-day advance notice to enrollees required for material modifications to the Summary of Benefits and Coverages (SBC). However, notice of the SBC changes must be provided as soon as reasonably practicable.

The HHS also won’t take enforcement action against insurers that adopt midyear changes to increase coverage for services related to COVID-19 diagnosis or treatment. But if plans or insurers maintain changes beyond the federal emergency health declaration period, they must comply with all other applicable requirements to update plan documents or terms of coverage. The HHS will take enforcement action against a plan or insurer that attempts to limit or eliminate other benefits or increase cost-sharing to offset the costs of increasing benefits related to COVID-19 diagnosis or treatment.

Telehealth and other remote care services

A temporary safe harbor has been established allowing high-deductible health plans (HDHPs) to cover telehealth and other remote care services without a deductible for plan years beginning on or before December 31, 2021. This safe harbor applies generally to HDHP coverage for telehealth and other remote care services and isn’t limited to coverage for COVID-19-related services.

In addition, the HHS will apply the nonenforcement policy described above if plans or insurers add benefits, or reduce or eliminate cost-sharing, for telehealth and other remote care services. However, to the extent plans or insurers maintain changes beyond the emergency health declaration period, they must comply with all other applicable requirements to update plan documents or terms of coverage.

Managing the impact

Further guidance may have been issued by the time you read this. Consult your benefits advisor for the latest on the FFCRA, CARES Act or any other compliance aspect of managing the impact of COVID-19.

Team

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