March 12, 2020 – CMS Publishes FAQs to Ensure Individuals, Issuers and States have Clear Information on Coverage Benefits for COVID-19
Yes. EHB generally includes coverage for the diagnosis and treatment of COVID-19. However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered. Non-grandfathered health insurance plans purchased by individuals and small employers, including qualified health plans purchased on the Exchanges, must provide coverage for ten categories of EHB.1 These ten categories of benefits include, among other things, hospitalization and laboratory services. Under current regulation, each state and the District of Columbia generally determines the specific benefits that plans in that state must cover within the ten EHB categories. This standard set of benefits determined by the state is called the EHB-benchmark plan. All 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of COVID-19.2
Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and will be waiving any cost-sharing that would otherwise apply to the test. Furthermore, many states are encouraging their issuers to cover a variety of COVID-19 related services, including testing and treatment, without cost-sharing, while several states have announced that health plans in the state must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing. 1. Grandfathered health plans are health plans that were in existence as of March 23, 2010, the date of enactment of Patient Protection and Affordable Care Act (PPACA), and that are only subject to certain provisions of PPACA, as long as they maintain status as grandfathered health plans under the applicable rules.
All EHB-benchmark plans cover medically necessary hospitalizations. Medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission are generally covered as EHB. The cost-sharing and specific coverage limitations associated with these services may vary by plan. For example, some plans may require prior authorization before these services are covered or may apply other limitations. Quarantine outside of a hospital setting, such as a home, is not a medical benefit, nor is it required as EHB. However, other medical benefits that occur in the home that are required by and under the supervision of a medical provider, such as home health care or telemedicine, may be covered as EHB, but may require prior authorization or be subject to cost-sharing or other limitations. 2. For information on the EHB-benchmark plans, see: https://www.cms.gov/CCIIO/Resources/Data-Resources/ehb.
A COVID-19 vaccine does not currently exist. However, current law and regulations require specific vaccines to be covered as EHB without cost-sharing, and before meeting any applicable deductible, when the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, if ACIP recommends a new vaccine, plans are not required to cover the vaccine until the beginning of the plan year that is 12 months after ACIP issues the recommendation. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost-sharing, prior to that date.
In addition, as part of a plan’s responsibility to cover prescription drugs as EHB, as described above to cover ACIP-recommended vaccines, if a plan does not provide coverage of a vaccine (or other prescription drugs) on the plan’s formulary enrollees may use the plan’s drug exceptions process to request that the vaccine be covered under their plan, pursuant to 45 CFR 156.122(c).
Center for Medicare and Medicaid Press Release Corona Virus Covid-19
Today, the Centers for Medicare & Medicaid Services (CMS) is posting Frequently Asked Questions (FAQs) on Essential Health Benefits (EHB) Coverage in response to the 2019 Novel Coronavirus (COVID-19) outbreak. This action is part of the broader, ongoing effort by the White House Coronavirus Task Force to ensure that all Americans – particularly those at high-risk of complications from the COVID-19 virus – have access to the health benefits that can help keep them healthy while helping to contain the spread of this disease.
“Amid a serious outbreak like this one, Americans understandably crave the security and peace of mind that comes from understanding exactly how they will be covered.” said CMS Administrator Seema Verma. “Today’s guidance aims to give it to them. Working closely with states and issuers around the country, the Trump Administration will continue to provide pertinent information to strengthen the nation’s response and keep Americans informed.”
The FAQs released today detail existing federal rules governing health coverage provided through the individual and small group insurance markets that apply to the diagnosis and treatment of COVID-19. The FAQs clarify which COVID-related services, including testing, isolation/quarantine, and vaccination, are generally currently covered as EHBs in these markets. The purpose of the FAQs is to provide guidance to Americans enrolled in individual or small group market health plans, including HealthCare.gov consumers. As questions and issues continue to come to CMS, they will be addressed and added to these FAQs.
Earlier this week, President Trump and Vice President Pence held a meeting with leading insurance companies and their industry associations in which many health insurance issuers announced they will be treating COVID-19 diagnostic tests as covered benefits and will be waiving cost-sharing that would otherwise apply to the tests. States are the primary regulators of health coverage and are continuing to work with issuers to ensure coverage of COVID-19 related services. Patients should contact their insurer to determine specific benefits and coverage policies, as these details may vary by state and by plan.
The COVID-19 FAQs for EHB can be found here: https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/EHB-Benchmark-Coverage-of-COVID-19.pdf
These FAQs, and earlier CMS actions in response to the COVID-19 virus, are part of the ongoing White House Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19 click here www.coronavirus.gov. For information specific to CMS, please visit the Current Emergencies Website.
Summary of CMS Public Health Action on COVID-19 to date:
March 12, 2020: CMS issued Frequently Asked Questions (FAQs) to aid state Medicaid and Children’s Health Insurance Program (CHIP) agencies in their response to the 2019 Novel Coronavirus (COVID-19) outbreak. CMS is taking this action in its continuing efforts to protect the health and safety of providers and patients, including those who are covered by Medicaid and CHIP.
March 10, 2020: CMS issued guidance to home health agencies and dialysis facilities with actionable information for healthcare workers on screening, treatment and transfer procedures to follow when interacting with patients in response to the 2019 Novel Coronavirus (COVID-19) outbreak.
March 10, 2020: CMS issued a frequently asked questions to ensure State Survey Agencies and accrediting organizations charged with inspecting nursing homes and other health care facilities, understand that non-emergency survey inspections are suspended. This shift in survey prioritization enables State Inspectors to address the spread of the 2019 Novel Coronavirus Disease (COVID-19).
March 10, 2020: CMS issued guidance on Medicare Advantage (MA) and Part D health and prescription drug plans informing them of the flexibilities they have to provide healthcare coverage for testing, treatments, and prevention of 2019 Novel Coronavirus Disease (COVID-19). Leading insurance companies and their industry associations announced they will be treating COVID-19 diagnostic tests as covered benefits and will be waiving cost sharing that would otherwise apply to the test.
March 10, 2020: CMS issued guidance on the range of facemasks that can be temporarily used based on recent changes to CDC and FDA facemask and respirator guidance in light of COVID-19 and supply demands. These are steps the White House Task Force is taking to ensure a maximum supply of facemasks and respirators are available that allow healthcare providers to safely treat patients without exposing themselves or others to COVID-19.
On March 9, 2020: CMS delivered detailed guidance on the screening, treatment and transfer procedures healthcare workers must follow when interacting with patients to prevent the spread of COVID-19 in a hospice setting. CMS also issued additional guidance specific to nursing homes to help control and prevent the spread of the virus.
On March 9, 2020: CMS issued a fact sheet with additional guidance for healthcare providers and patients about the telehealth benefits in the agency’s Medicare program. Expanded use of virtual care, such as virtual check-ins, are important tools for keeping beneficiaries healthy, while helping to contain the community spread of the COVID-19 virus.
On March 9, 2020: CMS published guidance to hospitals with emergency departments (EDs) on patient screening, treatment and transfer requirements to prevent the spread of infectious disease and illness, including COVID-19. Medicare-participating hospitals are to follow both CDC guidance for infection control and Emergency Medical Treatment and Labor Act (EMTALA) requirements.
March 6, 2020: CMS issued frequently asked questions and answers (FAQs) for healthcare providers regarding Medicare payment for laboratory test and other services related to the 2019-Novel Coronavirus (COVID-19).
March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs.
March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare.
February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19.
February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2.
February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19.