FAQs (Part 44) Clarify Health Plan Coverage of COVID-19 Tests and Vaccines

The DOL, IRS, and HHS have issued another round of FAQ guidance addressing implementation of the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) for group health plans. As background, the FFCRA and CARES Act, along with implementing regulations (see our Checkpoint article), generally require group health plans and insurers to cover COVID-19 diagnostic testing without cost-sharing, prior authorization, or other medical management requirements. Non-grandfathered group health plans and insurers must also cover “qualifying coronavirus preventive services,” including vaccines recommended by the CDC’s Advisory Committee on Immunization Practices, without cost-sharing and on an expedited basis. Here are highlights of FAQs Part 44, which clarify and build on previous guidance (see our Checkpoint article):

• Diagnostic Tests. Q/A-1 clarifies that plans cannot use medical-screening criteria to deny or impose cost-sharing on claims for COVID-19 testing and cannot require the presence of symptoms or recent known or suspected exposure as a condition of coverage. However, Q/A-2 confirms that plans are not required to cover testing for public health surveillance or employment purposes. Plans are encouraged to provide clear communications about the circumstances in which testing is covered. Q/As -3 and -4 clarify that plans must cover COVID-19 diagnostic tests provided through state- or locality-administered testing sites, including drive-through sites and those that do not require appointments, and that point-of-care (i.e., rapid) tests must be covered on the same basis as other tests. Q/A-5 reinforces previous guidance requiring coverage for items and services furnished during provider visits that result in an order for or administration of a COVID-19 diagnostic test and states that the agencies will take enforcement action where necessary to protect plan participants from inappropriate cost-sharing. Q/A-6 encourages plans to report providers of COVID-19 tests that violate the requirement to post cash prices for diagnostic tests or otherwise act in bad faith.
• Preventive Services, Including Vaccines. Q/A-7 states that plans must cover without cost-sharing all COVID-19 vaccines that have received a recommendation that makes them a qualifying coronavirus preventive service. Q/As -8 and -9 remind plans that vaccines must be covered no later than 15 business days after receiving the applicable recommendation and that the cost of vaccine administration must be covered regardless of whether a third party (such as the federal government) pays for the vaccine itself, or whether multiple doses are required. Q/A-10 explains that a plan cannot deny vaccine coverage merely because a participant does not currently meet a state’s or locality’s vaccination priority criteria. But a decision by an individual’s provider not to administer the vaccine because the individual is not in a prioritization category is not an adverse benefit determination subject to the plan’s claims and appeals requirements.
• SBC Notice Requirements. Q/A-11 elaborates on previous guidance allowing plans to enhance benefits for COVID-19 diagnosis or treatment or for telehealth services during the COVID-19 emergency without providing the minimum 60-day advance notice generally required for material modifications to the plan’s Summary of Benefits and Coverage. FAQs Part 42 (see our Checkpoint article) stated that the plan must provide notice of the changes as soon as reasonably practicable. Q/A-11 extends this guidance to include the addition of coverage for qualifying coronavirus preventive services.
• Employee Assistance Plans (EAPs) and On-Site Medical Clinics. EAPs are considered excepted benefits so long as (among other things) they do not provide significant benefits in the nature of medical care. On-site medical clinics are excepted benefits in all circumstances. FAQs Part 42 clarified that EAP or on-site medical clinic coverage of COVID-19 diagnostic tests while a COVID-19 federal emergency health declaration is in effect does not affect excepted benefit status. Q/A-12 extends this guidance to include coverage of COVID-19 vaccines and their administration.

EBIA Comment: As the COVID-19 pandemic continues (albeit with a light at the end of the proverbial tunnel), these FAQs are a must-read for group health plan sponsors and advisors. The agencies have clearly signaled that any exceptions to mandatory coverage of COVID-19 diagnostic testing and immunizations will be strictly and narrowly construed. For more information, see EBIA’s Group Health Plan Mandates manual at Section XVI.C (“Mandated Coverage of Diagnostic and Preventive Services”). See also EBIA’s ERISA Compliance manual at Section XXIV.O (“Summary of Benefits and Coverage (SBC) Under Health Care Reform”), EBIA’s Health Care Reform manual at Section XII.C (“Coverage of Preventive Health Services”), and EBIA’s HIPAA Portability, Privacy & Security manual at Sections VI.F (“Excepted Benefits: Certain Health FSAs, Dental, Vision, and Others”) and VI.L (“Employee Assistance Programs (EAPs)”).

Contributing Editors: EBIA Staff.