Agencies Provide Additional Guidance On Group Health Plan Coverage For COVID-19 Tests

by Caroline Nelsen

July 20, 2020

When the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) were passed earlier this year, both laws included group health plan requirements relating to coverage for testing, diagnosis and other costs related to COVID-19. The Department of Labor (DOL), the Department of Health and Human Services (HHS) and the Department of the Treasury (collectively, the Agencies) recently released a list of FAQs further clarifying what COVID-19 costs must be covered under group health plans, which include both fully-insured and self-funded employer-sponsored plans.

Coverage for Testing. Given the large number of COVID-19 tests available to the public and the various circumstances under which an individual might get tested, the FAQs clarified that group health plans are required to provide coverage for the following types of tests:

  • Tests approved by the Food and Drug Administration (FDA);
  • Tests the developer has requested or intends to request emergency use authorization (EUA) from the FDA (including in vitro diagnostic tests);
  • Tests developed in and authorized by the State, where HHS has been notified of its intention to review tests intended to diagnose COVID-19;
  • At-home tests ordered by an attending health care provider;
  • Coverage for all tests received by a participant, if a participant must undergo multiple COVID-19 tests (no numerical limit applies);
  • Tests ordered by a provider other than a participant’s attending health care provider, assuming the provider meets certain criteria; and
  • Other tests determined appropriate by HHS guidance.

Testing Coverage Exclusions. The FAQs also outline specific instances when testing does not need to be covered by a group health plan. Any testing conducted for general workplace health and safety (such as testing done to determine if an individual can safely return to work), testing done for surveillance of the public health, or testing for any other purpose not primarily intended for individualized diagnosis or treatment of COVID-19 or another health condition are not required to be covered by group health plans.

Coverage of Other Costs Incurred from COVID-19 Testing. Aside from the cost for the COVID-19 test itself, group health plans are also required to cover facility fees (such as a fee to use an x-ray machine) incurred during the process of administering a COVID-19 test or determining if a COVID-19 test is needed.

Balance Billing Prohibited. The Agencies intend to ensure that participants do not incur any cost-sharing with respect to the aforementioned COVID-19 testing costs and related expenses. The FAQs clarify that the requirement to provide coverage without cost sharing implies that balance billing is prohibited under the statute. The amount a group health plan reimburses a provider (either at a negotiated rate or cash price) constitutes payment in full for the test with no cost-sharing to the individual or other balance due.

Temporary Relief. The FAQs also provide temporary relief permitting large employers to offer a standalone group health plan that provides only limited coverage for telehealth and remote care services to employees who are not otherwise eligible under any other group health plans offered by the employer, even though those employees do not have major medical coverage through the employer. However, the Agencies clarified that certain other standards will still apply to such coverage (including, but not limited to, the prohibition on pre-existing condition exclusions, nondiscrimination requirements, etc.).

If you have any questions regarding COVID-19 testing coverage by group health plans, or any other questions pertaining to benefits during the pandemic, please do not hesitate to reach out to a member of the McGrath North Employee Benefits Group.

Employee Benefits:

Peter Langdon
(402) 633-1425

Joan Cannon
(402) 633-1430

Caroline Nelsen
(402) 633-9575

Contact information for the complete McGrath North’s COVID-19 Response Team can be found here.

For information regarding additional business-related concerns centered around COVID-19, please visit our COVID-19 Resource Guide here.

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