QUESTION: Throughout the pandemic, our company’s group health plan has covered COVID-19 testing and vaccines at no cost to plan participants. Is this still required now that the public health emergency has ended?
ANSWER: During the COVID-19 public health emergency (PHE), which ended May 11, 2023, group health plans were required to cover COVID-19 testing with no cost-sharing, prior authorization, or other medical management restrictions. In addition, non-grandfathered health plans were required to provide coverage for COVID-19 vaccines, also at no cost and without medical management restrictions. Regulations and agency guidance clarified the extent of the required coverage (see, for example, our Checkpoint article). The agencies have also provided guidance regarding coverage following the end of the PHE (see our Checkpoint article).
The diagnostic testing coverage requirements no longer apply to items or services furnished after the end of the PHE. The agencies have explained that over-the-counter tests are considered “furnished” on the date of purchase. For testing by a health provider, plans should look to the earliest date on which a service was rendered to determine whether the service was furnished during the PHE. For example, if a health provider collects a specimen to perform COVID-19 testing on the last day of the PHE, but the laboratory analysis occurs on a later date, both the collection and the analysis should be treated as furnished during the PHE. The agencies have encouraged plans to continue providing coverage for COVID-19 testing beyond the PHE at no cost to participants. However, plans may choose not to cover the tests or to cover them while imposing cost-sharing or out-of-network limitations.
Unlike the diagnostic testing coverage requirement, the requirement to provide COVID-19 preventive services (vaccines) is not limited to the duration of the PHE. As a result, the preventive coverage requirement is ongoing for non-grandfathered health plans. However, with the end of the PHE, plans are no longer required to provide coverage for COVID-19 vaccines delivered by out-of-network providers if the plan has a network of providers. If coverage is provided for out-of-network preventive services, plans may impose cost-sharing if there is an in-network provider who can provide the service.
The agencies have encouraged plans to notify participants and beneficiaries of any changes to the terms of the plan’s coverage for COVID-related services. In general, material modifications that would affect the content of the plan’s summary of benefits and coverage (SBC) must be disclosed no later than 60 days before the modification’s effective date. However, plans that increased benefits or reduced cost-sharing for COVID-related items and services and revoke these changes upon the PHE’s expiration will be deemed in compliance with the advance notice requirement if they previously notified participants (during the current plan year) of the general duration of the increased benefits or if they notify participants within a reasonable time in advance of the reversal. Also, ERISA requires that an SMM be furnished no later than 60 days after adoption of a material reduction in a plan’s covered services or benefits.
For more information, see EBIA’s Group Health Plan Mandates manual at Section XVI.C (“COVID-19: Mandated Coverage of Diagnostic and Preventive Services”).
Contributing Editors: EBIA Staff.