COVID-19 Legislation and Other State Requirements

As COVID-19 continues to test the capacity of the healthcare system in certain areas, some states have directed insurers and their utilization review agents, and encouraged third party administrators for their self-funded clients to temporarily suspend utilization management medical necessity reviews to allow providers to focus on treating patients. 

We’ve gathered the latest updates from states, networks, utilization review vendors, and our preferred stop-loss carriers.

On March 27, 2020, the President signed The Coronavirus Aid, Relief, and Economic Security (CARES) Act in response to the COVID-19 pandemic. Here are some highlights of the legislation that impact self-funded health benefit plans:

Testing Coverage Without Any Cost Sharing for COVID-19  

Individual and group health plans, including both fully-insured and self-insured, must cover COVID-19 testing, whether or not that testing is FDA-authorized. This provision is an update of the previous stimulus package that required coverage for FDA-authorized tests only.

Payment Amount for COVID-19 Testing and Related Services

Self-insured health plans and insurance carriers must pay the provider performing the testing for COVID-19 (along with costs incurred during the medical visit when testing is performed) at an amount equal to their in-network negotiated rate for the testing and related services. 

If the carrier or self-insured plan does NOT have a negotiated payment rate, or does not then negotiate a specified price with the provider, the payment amount should equal the cash price of the service, which the provider is required to post on the provider’s publicly available Internet site.

No Required Payment for COVID Treatment

This legislation does NOT require coverage for treatment of COVID-19 (only for testing and related services), so benefits will be administered in accordance with the terms of the health benefit plan document. However, further legislation on this issue could be forthcoming.  

Coverage Without Any Cost Sharing for COVID-19 Vaccine

Once a COVID-19 vaccine is developed and “recommended” as a preventive service, insurance carriers and self-insured plans must cover the cost of the vaccine without any cost-sharing. This requirement would go into effect 15 business days after the U.S. Preventive Service Task Force rates it an “A” or “B” or after it is recommended by the Advisory Committee on Immunization Practices of the CDC.  

HSA-Eligible HDHP Exemption for Telehealth

An HSA-eligible HDHP is allowed to pay for the costs associated with a telehealth visit before the deductible is met. The member would also continue to be eligible to make tax-free contributions to their HSA. This exemption is only available for plan years beginning on or before December 31, 2021.  

HSA/FSA Payments for Feminine Hygiene and OTC Drugs

A patient may use an HSA/FSA/HRA to purchase over-the-counter medicine and menstrual care products.

On March 18, the President signed H.R. 6201—the Families First Coronavirus Response Act (FFCRA)—to provide relief during this global pandemic.

Here’s what you need to know:
During any portion of the declared emergency period, self-funded ERISA and non-ERISA (church, state and local governmental plans) group health plans and health insurers offering group or individual health insurance coverage—including grandfathered health plans:

• Must provide coverage
• Must not impose any cost sharing requirements, including deductibles, co-payments, and coinsurance
• Must not impose prior authorization or other medical management requirements

For the following items and services furnished:

• In vitro diagnostic products  for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19 that are approved, cleared, or authorized under section 510(k), 513, 515 or 564 of the Federal Food, Drug, and Cosmetic Act, and the administration of such in vitro diagnostic products.
• Items and services furnished to an individual during healthcare provider office visits—including in-person visits, telehealth visits, urgent care center visits, and emergency room visits—that result in use of the diagnostic product described above.

Any members paying a copay for Teladoc (Trustmark Health Benefits’ telemedicine solution) consultation resulting in the above mentioned diagnostic tests will be reimbursed via a check sent to the member’s home for the amount of the consult fee.

To view information regarding pricing of COVID-19 tests, click here.

The FFCRA provides businesses with fewer than 500 employees refundable tax credits to reimburse them for the cost of providing paid sick and family leave wages related to COVID-19. The IRS has released comprehensive FAQs about these tax credits for employers providing this paid leave as required in the FFCRA.