How does diagnosis and treatment of the coronavirus (COVID-19) apply to group health plans?


On March 5th, CMS released guidance related to federal rules governing health insurance coverage for coronavirus (COVID-19). 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.


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


In addition, 3 states have already said that insurance carriers with fully-insured plans located in that state must cover diagnostic testing and related visits for the purpose of COVID-19 screenings with no cost-sharing. In other words, fully-insured plans in these states may not charge a deductible, copay or coinsurance for screenings related to COVID-19. So far, those states include New York, California and Washington state, but other states may soon follow suit.


CMS Notice: https://www.cms.gov/files/document/03052020-individual-small-market-covid-19-fact-sheet.pdf

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