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Departments Provide FAQs to Clarify FFCRA and CARES Act Mandates to Group Health Plans

On April 11, 2020, the Departments (DOL, HHS and IRS) issued a set of FAQs on implementation of the FFCRA and CARES Act as it relates to group health plans. 

The FFCRA requires health plans to cover certain diagnostic tests and related services for the detection of COVID-19. The CARES Act expands this to include a broader range of testing and requires the carriers or health plan to reimburse any provider of diagnostic tests the cash price listed on the provider’s public website or the negotiated rate.

Here are some of the FAQ's main points:

  • Mandated coverage of diagnostic tests:  health plans and carriers must cover in vitro diagnostic tests and the administration of those tests that are either approved by the FDA, authorized by FDA for emergency use, authorized by the state, or deemed appropriate by HHS. Also, serological tests to detect antibodies for COVID-19 are considered diagnostic tests and must be covered with no cost-sharing.

  • Mandated coverage for office visits related to COVID-19 testing: No cost sharing is allowed for other services during health care provider office visits (including in-person and telehealth visits and drive-through screening and testing visits), urgent care center visits, and ER visits that result in an order for a test or actual administration of a diagnostic test, but only if the items and services relate to the administration of the test or to determine the need for the test. 

For example, if the provider determines that a flu test or blood test should be performed during a visit to determine the patient’s need for a COVID-19 test and the visit results in an order for, or administration of, a diagnostic test, the plan or insurer must provide coverage for the related tests without cost-sharing, prior authorization, or other requirements. However, if the provider doesn’t order or administer a COVID-19 test,  then no part of the visit would be subject to the FFCRA, and normal cost-sharing under the plan’s terms would apply. 

  • Payment to providers (in and out of network): The plan or insurer must reimburse the provider, whether in-network or out of network, for COVID-19 diagnostic testing and related services. The reimbursement amount is either the negotiated rate in effect prior to the public health emergency, or the cash price listed on the provider's public website.

  • EAPs and onsite clinic benefits: EAPs are considered excepted benefits only if the EAP does not provide significant benefits in the nature of medical care. An EAP won’t be seen as providing benefits that are “significant in the nature of medical care” only because it covers diagnostic tests while a COVID-19 federal emergency health declaration is in effect. Also, an employer’s onsite clinic can cover COVID-19 tests without losing excepted benefit status.

  • SBCs and Plan Modifications: The departments will not take enforcement action against plans or carriers that adopt coverage changes for COVID-19 diagnosis or treatment without providing the minimum 60-day advance notice to enrollees required for material modifications to the Summary of Benefits and Coverages (SBC), as long as notice of the changes is provided as soon as reasonably practicable. However, if plans keep changes beyond the federal emergency health declaration period, they must comply with all other requirements to update plan documents or coverage terms. In addition, HHS will take enforcement action against a plan or insurer that attempts to limit or eliminate other benefits or increase cost-sharing to offset the costs of increasing benefits related to COVID-19 diagnosis or treatment.

  • Coverage of Telehealth: The temporary safe harbor allowing HDHPs to cover telehealth without a deductible for plan years beginning on or before December 31, 2021, applies to HDHP coverage and is not limited only to coverage for COVID-19-related services. In other words, employers can offer a telehealth benefit that has no cost sharing with an HDHP, which will not be considered disqualifying first-dollar coverage.  

In addition, HHS will apply the nonenforcement policy described above if plans or insurers add benefits, or reduce or eliminate cost-sharing, for telehealth and other remote care services. However, if plans or insurers maintain changes beyond the emergency health declaration period, they must comply with all other requirements to update plan documents or terms of coverage.

The FFCRA’s mandates apply to most carriers and group health plans, including fully-insured, self-insured and grandfathered plans. During the pandemic, It is important for employers to communicate these changes to employees, and work with carriers and TPAs to make sure they understand what the plan has to cover or chooses to cover beyond what is mandated under the FFCRA.

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