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Should Our Group Well being Plan Proceed to Cowl COVID-19 Testing and Vaccines After the Public Well being Emergency Has Ended?


QUESTION: All through the pandemic, our firm’s group well being plan has lined COVID-19 testing and vaccines for free of charge to plan members. Is that this nonetheless required now that the general public well being emergency has ended?

ANSWER: Throughout the COVID-19 public well being emergency (PHE), which ended Might 11, 2023, group well being plans had been required to cowl COVID-19 testing with no cost-sharing, prior authorization, or different medical administration restrictions. As well as, non-grandfathered well being plans had been required to offer protection for COVID-19 vaccines, additionally for free of charge and with out medical administration restrictions. Laws and company steering clarified the extent of the required protection (see, for instance, our Checkpoint article). The companies have additionally offered steering concerning protection following the tip of the PHE (see our Checkpoint article).

The diagnostic testing protection necessities not apply to gadgets or providers furnished after the tip of the PHE. The companies have defined that over-the-counter checks are thought-about “furnished” on the date of buy. For testing by a well being supplier, plans ought to look to the earliest date on which a service was rendered to find out whether or not the service was furnished throughout the PHE. For instance, if a well being supplier collects a specimen to carry out COVID-19 testing on the final day of the PHE, however the laboratory evaluation happens on a later date, each the gathering and the evaluation must be handled as furnished throughout the PHE. The companies have inspired plans to proceed offering protection for COVID-19 testing past the PHE for free of charge to members. Nonetheless, plans might select to not cowl the checks or to cowl them whereas imposing cost-sharing or out-of-network limitations.

In contrast to the diagnostic testing protection requirement, the requirement to offer COVID-19 preventive providers (vaccines) shouldn’t be restricted to the length of the PHE. Consequently, the preventive protection requirement is ongoing for non-grandfathered well being plans. Nonetheless, with the tip of the PHE, plans are not required to offer protection for COVID-19 vaccines delivered by out-of-network suppliers if the plan has a community of suppliers. If protection is offered for out-of-network preventive providers, plans might impose cost-sharing if there may be an in-network supplier who can present the service.

The companies have inspired plans to inform members and beneficiaries of any modifications to the phrases of the plan’s protection for COVID-related providers. Typically, materials modifications that might have an effect on the content material of the plan’s abstract of advantages and protection (SBC) have to be disclosed no later than 60 days earlier than the modification’s efficient date. Nonetheless, plans that elevated advantages or lowered cost-sharing for COVID-related gadgets and providers and revoke these modifications upon the PHE’s expiration might be deemed in compliance with the advance discover requirement in the event that they beforehand notified members (throughout the present plan yr) of the overall length of the elevated advantages or in the event that they notify members inside an inexpensive time upfront of the reversal. Additionally, ERISA requires that an SMM be furnished no later than 60 days after adoption of a cloth discount in a plan’s lined providers or advantages.

For extra info, see EBIA’s Group Well being Plan Mandates guide at Part XVI.C (“COVID-19: Mandated Protection of Diagnostic and Preventive Companies”).

Contributing Editors: EBIA Employees.



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