Coverage for Small-Group Health Plans for Coronavirus

On March12th, CMS released FAQs related to federal rules governing health insurance coverage for coronavirus. Diagnosis and treatments of illnesses typically fall under categories of essential health benefits (EHBs), which must be covered by certain health plans.


Health insurance carriers offering coverage in the individual or small group market must ensure that the coverage includes essential health benefits. However, large group plans and self-insured plans are not subject to EHB coverage requirements, so whether an EHB is covered is based on the specific benchmark plan selected by each state and the plan’s terms.


As a reminder, EHBs include minimum benefits in 10 general categories and the items and services covered within these categories:


  • Ambulatory patient services

  • Emergency services

  • Hospitalization

  • Maternity and newborn care

  • Mental health and substance use disorder services, including behavioral health treatment

  • Prescription drugs

  • Rehabilitative and habilitative services and devices

  • Laboratory services

  • Preventive and wellness services and chronic disease management

  • Pediatric services, including oral and vision care


Health plans in the individual and small group markets must cover EHBs, which means setting limits on cost-sharing and providing coverage at specified actuarial levels.


CMS guidance points out that coverage for diagnosis and treatments for viral infections extend to coronavirus, and many of those would fall under categories of EHBs.


For example, lab services, prescription drugs and hospitalization are all broad categories of EHBs that individual and small group carriers are generally required by law to include in their benefit packages. However, cost-sharing for services related to the diagnosis and treatment of COVID-19 would vary by plan and by which state benchmark plan applies. Therefore, just because it is an EHB doesn’t mean there is no cost-sharing to the insured--deductibles, copays and coinsurance may be charged for EHBs.


Regarding quarantine, FAQ #2 points out that medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital stay are generally covered as EHB under hospitalization (subject to plan’s terms, deductible and coinsurance). Quarantine outside of a hospital, such as at home, is not a medical benefit and is therefore not an EHB. But other medical benefits that occur in the home that are required by and under the supervision of a medical provider, such as home health care or telemedicine, may be covered as EHB, but may require prior authorization or be subject to the plan’s deductible/coinsurance/copays.


Now, when a vaccine is developed and approved by the FDA for COVID-19, further guidance would likely be issued regarding whether the vaccine would have to be covered as a preventive service for which no cost sharing could be charged.


CMS FAQs: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/EHB-Benchmark-Coverage-of-COVID-19.pdf?mc_cid=a75adf8076&mc_eid=2b747fee9f

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