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Agencies Issue FAQs on Group Health Plan COVID-19 Coverage Requirements

On Behalf of | Apr 16, 2020 |

HHS, DOL and IRS (the “Agencies”) have jointly issued FAQ 42 to provide guidance on the implementation of the COVID-19 coverage requirements of the Families First Coronavirus Response Act (“FFCRA”) and the Coronavirus Aid, Relief, and Economic Security (“CARES”) Act.

The FFCRA generally requires group health plans and health insurance issuers offering group or individual health insurance coverage to provide benefits for certain items and services related to diagnostic testing for the detection of COVID-19 when those items or services are furnished on or after March 18, 2020, and during the “applicable emergency period”. Under the FFCRA, plans and issuers must generally provide this coverage without imposing any cost-sharing requirements (including deductibles, copayments, and coinsurance) or requiring prior authorization or other medical management requirements.

The CARES Act amended the FFCRA to include a broader range of diagnostic items and services that plans and issuers must cover without cost-sharing, prior authorization or other medical management requirements.

For these purposes. the term “group health plan” includes both insured and self-insured plans. It includes private employment-based group health plans (such as ERISA plans), non-federal governmental plans (such as plans sponsored by state and local governments), and church plans. “Individual health insurance coverage” includes coverage offered in the individual market through or outside of an Exchange, as well as student health insurance coverage. The requirements do not apply to short-term, limited-duration insurance or to excepted benefit programs such as certain employee assistance programs and on-site medical clinics. It also does not apply to group health plans that do not cover at least two current employees (such as plans in which only retirees participate).

Plans must cover in vitro diagnostic tests as well as related items and services furnished to an individual during healthcare provider office visits (including telehealth visits and other “non-traditional” services), urgent care center visits, and emergency room visits.

Plans and issuers generally may not impose any cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization requirements, or other medical management requirements for these items and services. The items and services must be covered without cost-sharing, when medically appropriate for the individual, as determined by the individual’s attending healthcare provider in accordance with accepted standards of current medical practice.

In the case of out-of-network providers, plans and issuers must reimburse any provider of COVID-19 diagnostic testing an amount that equals the negotiated rate or, if the plan or issuer does not have a negotiated rate with the provider, the cash price for such service that is listed by the provider on a public website. (The plan or issuer may negotiate a rate with the provider that is lower than the cash price.)

The FAQs say that states may impose additional requirements with regard to COVID-19 in addition to those required under federal law.

The Agencies will not commence any enforcement action if an employer does not provide required notices to employees (such as the advance notice of a material modification or a revised Summary of Coverage and Benefits) if such modification provides greater coverage related to the diagnosis and/or treatment of COVID-19. Plans and issuers must provide notice of the changes to participants as soon as reasonably practicable.

FAQ 42 can be found at: