The new federal COVID-19 testing benefits mandate does apply to major medical insurance policies, including employers’ self-insured health plans, and “grandfathered” health insurance policies.
The mandate does not apply to short-term health insurance.
Officials at three departments — the U.S. Department of Labor, the U.S. Treasury Department and the U.S. Department of Health and Human Services — gave given that interpretation in a new set of answers to frequently asked questions (FAQs) about the mandate.
- The new batches of CMS guidance are available here.
- An article about what states have been doing about COVID-19 testing benefits is available here.
The so-called “tri agency team” developed the guidance to interpret the health insurance sections of the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security Act (CARES Act).
Section 6001 of the FFCRA requires group health plans and health insurance issuers to cover testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19 pneumonia and heart damage, without imposing deductibles, co-payment requirements, or other cost-sharing requirements or prior authorization requirements on the patients.
Outside the Section 6001 Fence
Jeff Smedsrud, the founder of Pivot Health, a company that sells short-term health insurance, said recently in an interview with ThinkAdvisor that many short-term health insurance issuers are providing coverage for COVID-19 testing.
But tri-agency officials say in the new guidance that the Section 6001 COVID-19 testing benefits mandate has no effect on “excepted benefits,” or health insurance products that are excepted from the federal requirements that apply to major medical insurance.
The list of excepted benefits includes products such as dental insurance, disability insurance, hospital indemnity insurance, and short-term health insurance.
Although the Section 6001 mandate applies to group health plans, it “does not apply to group health plans that do not cover at least two employees who are current employees (such as plans in which only retirees participate,” officials write.
Inside the Section 6001 Fence
Officials say the new mandate does apply to grandfathered plans, or major medical insurance arrangements that have been in place since before 2010, when the Affordable Care Act became law.
The mandate also applies to fully insured group health plans, wholly or partly self-insured group health plans, state and local government employee health plans, church plans, ACA exchange plans, individual major medical insurance sold outside the ACA public exchange system, and student health insurance, officials say.
Section 3202(a) of the CARES Act lets a health plan or health insurer pay a provider a negotiated price for a SARS-CoV-2 test or diagnostic procedure.
“If the plan or issuer does not have a negotiated rate with such provider, the plan or issuer shall reimburse the provider in an amount that equals the cash price for such service as listed by the provider on a public internet website, or the plan or issuer may negotiate a rate with the provider for less than such cash price,” according to the guidance text.
The tri agencies put many batches of ACA guidance through public comment periods.
The agencies say they are using discretion to adopt the new interpretations as temporary policies of relaxed enforcement.
“The departments therefore believe that this guidance is a statement of policy not subject to the notice and comment requirements of the Administrative Procedure Act,” the tri agencies say.
— Read Short-Term Health Insurers Are Mobilizing, Too: Jeff Smedsrud, on ThinkAdvisor.