The IRS, U.S. Department of Labor, and Department of Health and Human Services recently issued interim final regulations addressing group health plan coverage of COVID-19 preventive services — including vaccinations — and testing. The regulations are effective immediately and will sunset at the end of the COVID-19 public health emergency.
Qualifying preventive services
The regulations implement the CARES Act requirement that most group health plans cover — without cost-sharing — qualifying coronavirus preventive services that receive specified recommendations from the Centers for Disease Control (CDC). This includes immunizations. Coverage must be provided within 15 days after the CDC’s recommendation, regardless of whether the service or immunization is recommended for routine use and whether it’s provided by an in-network or out-of-network provider.
In contrast, the Affordable Care Act rules for preventive services generally allow plans at least a year after the CDC recommendation to begin coverage. And coverage is only required for services and immunizations approved for routine use and provided by in-network providers, with limited exceptions.
Plans must cover the cost of a vaccine’s administration — even if the cost of the vaccine itself is paid by a third party such as the federal government. Plans may impose cost-sharing for office visits that are billed separately, but office visits not billed separately must be covered without cost-sharing if the primary purpose of the visit is for the administration of the vaccine. Although grandfathered plans and plans providing excepted benefits or short-term, limited-duration coverage aren’t required to comply with the rules regarding qualifying coronavirus preventive services, an accompanying toolkit makes clear that they’re encouraged to do so.
The cost of testing
The CARES Act requires group health plans (including grandfathered plans and those providing excepted benefits or short-term, limited-duration insurance) to cover a broad range of COVID-19-related diagnostic items and services. Group health plans also must reimburse any provider of diagnostic tests (in-network or out-of-network) the cash price listed by the provider on a public website or a lower negotiated rate. To address plan concerns about providers failing to post cash prices, the regulations provide further posting instructions and details about how the requirement will be enforced. The agencies seek comments on related issues, including whether the posting requirement should be expanded to include providers that perform additional services related to COVID-19 testing (such as specimen collection or transportation).
In addition, the agencies note that COVID-19 testing efforts have been hampered by challenges such as delays in obtaining results, test accuracy, and supply shortages. Plans are encouraged to explore pay-for-performance arrangements that would incentivize providers to reduce the time it takes to report test results while still maintaining accuracy.
Prepare now
The agencies have issued a wealth of guidance regarding required coverage of COVID-19 testing and vaccines, and this will likely not be the last of it. Although an approved COVID-19 vaccine isn’t yet publicly available, employers should prepare now to provide coverage without cost-sharing within 15 days of the CDC recommendation. Our firm can provide assistance on cost-effectively managing your organization’s health care benefits. We also recommend that patients check with their individual health plans to determine their specific coverage levels. © 2020