Multi-Agency FAQ Issued Regarding COVID-19 Testing And Vaccine Coverage By Health Plans

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On Friday February 26, 2021, several agencies including The Departments of Labor, health, and Humans Services (HHS) published FAQs regarding health insurance issuers’ obligations under the FFCRA and CARES Act for governing diagnosing testing for COVID-19 and related items and serves during the public health emergency. This new guidance is helpful for plans, providers, and individuals alike and provides clarity on the nuances of coverage for COVID-19 tests and vaccines.

Together, the FFCRA and CARES Act requires health insurance issuers to cover COVID-19 testing without patient cost share, prior authorization, or other medical management requirements. The FAQs clarify that health insurance plans and issuers may not use medical screening criteria to deny or impose cost share when a covered person that is asymptomatic and has no known or suspected exposure to COVID-19 obtains a COVID-19 test. Throughout the pandemic, there has been some gray area as to whether health plans must cover “non-medically necessary” COVID-19 tests, and therefore could impose requirements for coverage of a test, such as exposure to COVID-19 or symptoms. Most people could not simply obtain a COVID-19 test as a precaution. This guidance clarifies that the FFCRA and CARES Act require health plans to cover these precautionary tests. This clarification does not change previous guidance and these FAQs emphasize that while health plans cannot impose criteria for coverage of COVID-19 tests for individualized diagnosis or treatment, health plans are still not required to cover tests for the purpose of public health surveillance or employee required testing.

The FAQs address various issues with coverage and provider charges for COVID-19 services, including coverage for vaccines. In short, plans are required to cover all COVID-19 vaccines that have received CDC recommendation within 15 business days after the date the CDC’s Advisory Committee on Immunization Practices (ACIP) makes a recommendation regarding the vaccine. The FAQ goes into additional detail regarding when plans and issuers have to cover the vaccine administration fee. Notably, plans and issuers may not deny coverage for a vaccine if the beneficiary receiving the vaccine is not yet within the recommended “category” of persons designated by the CDC to receive a vaccine. Thus, if a non-frontline health worker that is neither over 65 nor has a preexisting condition receives a vaccine, health plans must still cover the vaccine without cost share.

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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