What Does Your Health Plan Have to Cover? New Federal Guidance on COVID-19 Testing and Vaccines

Earlier What You Need To Know Now postings here and here explained that, under the Families First Coronavirus Response Act and CARES Act, health plans are required to cover the cost of COVID-19 diagnostic testing and vaccination without any cost sharing (co-pays, deductibles, coinsurance).  On February 26, 2021, in accordance with President Biden’s COVID-19 Executive Order, three federal agencies  (The Centers for Medicare & Medicaid Services,  the Departments of Labor and Treasury) issued joint guidance clarifying health plans’ obligations regarding COVID -19 testing and vaccinations.  The guidance removes barriers to COVID-19 diagnostic testing and vaccinations and strengthens the requirements that health plans and health insurance issuers cover diagnostic testing without cost sharing.

Diagnostic Testing

• Plans cannot use medical screening to deny coverage or impose cost-sharing for COVID-19 diagnostic tests for individuals who are asymptomatic, and who have no known or suspected exposure to COVID-19.   Testing must be covered without prior authorization or other medical management requirements.  This means that individuals wanting to ensure they are COVID-19 negative prior to visiting a family member can get tested without paying cost sharing.  (However, plans are not required to cover testing for employment purposes or public health surveillance.)
• Plans and issuers must cover point-of-care (rapid) COVID-19 diagnostic tests, and COVID-19 diagnostic tests administered at state or locally administered testing sites, including drive-in sites and those not requiring appointments.
• Covered services such as in-person and telehealth visits to a health care provider, urgent care center, and emergency room that result in an order for or administration of a diagnostic test cannot be subject to cost-sharing.
• Health plans and insurers must reimburse the COVID-19 diagnostic testing provider, either at a negotiated rate or the provider’s rate.  If the reimbursement rate is not negotiated, the provider must make the cash price amount public or face enforcement actions or civil monetary penalties.

Vaccinations

• Plans and insurers must provide the qualifying COVID-19 vaccines (i.e., recommended by the CDC) and other preventive services without cost-sharing, even if there is an administration fee or multiple doses, or a third-party, such as the government, pays for the vaccine. Coverage of vaccination without cost-sharing is also required when an individual is not in the early vaccination category determined by the state or locality.

• However, a provider may decline to provide the vaccine to someone not in the early vaccination category. This denial is not considered an adverse benefit determination made by a plan or insurer and is therefore not subject to the plan’s claims and appeals process. 

These requirements are in effect for the duration of the public health emergency, which will likely be in effect for 2021.