Savoy Guide | New Guidance Released Regarding Coverage of Testing for COVID-19 and Coverage of COVID-19 Vaccines


Published: 03.02.2021

Overview: New guidance addresses how COVID testing and recommended vaccines are to be provided without imposing any cost-sharing requirements, prior authorization, or other medical management requirements.

The COVID testing rules apply to group health plans and health insurance issuers offering group or individual health insurance coverage, including grandfathered health plans, while the vaccine rules apply to fully and self-insured group and individual “non-grandfathered plans.”

Background: FFCRA generally requires group health plans and health insurance issuers offering group or individual health insurance coverage, including grandfathered health plans, to provide benefits related to testing for the COVID-19, or the diagnosis of COVID-19 during the public health emergency period. The public health emergency period has been extended several times, most recently effective January 21, 2021. The acting HHS Secretary announced that the public health emergency will likely remain in place for the duration of 2021. When a decision is made to terminate the declaration or let it expire, HHS will provide states with 60 days’ notice prior to termination. Plans and issuers must provide this coverage without imposing any cost-sharing requirements (including deductibles, copayments and coinsurance), prior authorization or other medical management requirements.

The CARES Act amended the FFCRA to include a broader range of diagnostic items and services such as the vaccine that plans, and issuers and non-grandfathered plans must cover without any cost-sharing requirements.

What: COVID “Individual” testing with no cost share or pre-authorization or medical management required
  • Applies to fully insured and self-insured, group, individual and grandfathered plans.
  • Applies to “individuals” receiving COVID-19 diagnostic test from a licensed or authorized health care provider, or when a licensed or authorized health care provider refers an individual for a COVID-19 diagnostic test, plans and issuers generally must assume that the test reflects an “individualized clinical assessment” and the test should be covered. FAQ Part 44, Q1.
  • Plans and issuers cannot use medical screening criteria to deny (or impose cost-sharing on) a claim for COVID-19 diagnostic testing for an asymptomatic person who has no known or suspected exposure to COVID-19. FAQ Part 44, Q1.
  • While plans and issuers are not required to provide coverage of testing for public health surveillance or employment purposes, they may do so. FAQ Part 44, Q2.
  • Plans and issuers may continue to employ programs designed to detect and address fraud and abuse. FAQ Part 44, Q6.
  • Individual diagnostic tests from a licensed or authorized provider State-or locality-administered site, a “drive-through” site, and/or a site that does not require appointments, are included in the no cost-share rules. FAQ Part 44, Q3.
  • Point of care diagnostic tests (rapid response test) must be covered without cost sharing under the FFCRA. FAQ Part 44, Q4.
Qualifying coronavirus preventive services (vaccines) are to be provided without cost-sharing requirements.  
  • Applies to non-grandfathered group health plans and health insurance issuers.
  • The term “qualifying coronavirus preventive service” means an item, service, or immunization that is intended to prevent or mitigate COVID-19 and that is-
    • An evidence-based item or service that has in effect a rating of “A” or “B” in the current recommendations of the US Preventive Services Task Force (USPSTF); or
    • An immunization that has in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP).
    • Currently, the Pfizer BioNTech COVID-19 and the Moderna COVID-19 vaccine received a recommendation from ACIP as did the Johnson & Johnson vaccine. FAQ Part 44, Q7.  
  • Plans and issuers must begin providing coverage for qualifying coronavirus preventive services without cost sharing starting no later than 15 business days (not including weekends or holidays) after the date the USPSTF or ACIP makes an applicable recommendation regarding a qualifying coronavirus preventive service. FAQ Part 44, Q8.
  • Plans and issuers must cover the vaccine administration fee when the plan or issuer is not billed for the vaccine. This includes covering without cost sharing the administration of a required preventive immunization in instances where a third party, such as the Federal Government, pays for the preventive immunization. FAQ Part 44, Q9.
  • A plan or issuer may not deny coverage of recommended COVID-19 vaccines because a participant, beneficiary, or enrollee is not in a category recommended for early vaccination. FAQ Part 44, Q10.
Notice Requirements
While the Departments will not take enforcement action against any plan or issuer that does not provide at least 60 days’ advance notice of a material modification regarding the addition of coverage for qualifying coronavirus preventive services, plans and issuers must provide notice as soon as reasonably practicable. FAQ Part 44, Q11.
 
Excepted Benefits
  • An EAP will not be considered to provide benefits that are significant in the nature of medical care solely because it offers benefits for COVID-19 vaccines and their administration (including when offered in combination with benefits for diagnosis and testing for COVID-19). However, there must be no cost-sharing to constitute excepted benefits and the EAP must comply with other applicable requirements. FAQ Part 44, Q12.
  • An employer may offer benefits for COVID-19 vaccines (and their administration) at an on-site medical clinic while remaining an excepted benefit. FAQ Part 44, Q13.
Provider Relief
Health care providers can seek reimbursement when delivering COVID-19 related services to the uninsured through two sources of federal funding. The FFCRA Relief Fund and the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA) collectively appropriated to reimburse providers for COVID-19 testing for uninsured individuals. Additionally, the CARES Act established a Provider Relief Fund (PRF). FAQ Part 44, Q14.
 
FAQs have been prepared jointly by the Departments of Labor, Health and Human Services, and the Treasury (collectively, the Departments), Published February 26, 2021 / FAQ Part 44 Cover Page (cms.gov)