CMS Issues FAQs Regarding FFCRA and CARES Act COVID-19 Testing and Vaccination Requirements
On February 26, 2021, CMS, in partnership with the DOL, HHS and Treasury, issued a set of 14 FAQs that address FFCRA and CARES Act issues. Specifically, the FAQs cover issues relating to the requirement that plans and issuers cover COVID-19 testing and vaccinations without cost sharing and other requirements. The FAQs also discuss the circumstances under which an employer can offer COVID-19 vaccines through an EAP or an on-site medical clinic. Finally, the FAQs include information about how providers may seek federal reimbursement when delivering COVID-19 related services to the uninsured.
The FFCRA includes a requirement (as amended by the CARES Act), that group health plans and health insurance issuers offering group or individual health insurance coverage, including grandfathered health plans, provide benefits for certain items and services related to diagnostic testing for COVID-19, without imposing any cost-sharing requirements, prior authorization or other medical management requirements. The CARES Act also requires non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage to cover, without cost sharing, qualifying coronavirus preventive services, including recommended COVID-19 vaccines.
Coverage of previous FAQs on this topic can be found in NFP’s Latest Insights page COVID-19-Related Benefits Compliance Resources Available (nfp.com)
This document stresses that these requirements apply when an individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized healthcare provider, or when a licensed or authorized healthcare provider refers an individual for a COVID-19 diagnostic test. Under these circumstances, plans and issuers must assume that the receipt of the test reflects an “individualized clinical assessment,” and the test should be covered without cost sharing, prior authorization or other medical management requirements.
The FAQs further apply this concept by pointing out that the requirement covers such testing for asymptomatic persons who are not known to be exposed to COVID-19, but it does not cover such testing when it is done for public health surveillance or employment purposes (which are not administered under the same conditions as an “individualized clinical assessment”). However, plans are encouraged to cover such testing and to clearly communicate with plan participants when the testing is covered and when it is not, and to implement programs to prevent fraud and abuse.
The FAQs point out that the FFCRA and the CARES Act make no distinction between point-of-care and other tests, and that the statutes make no distinction as to where the tests are administered; if they are “individualized clinical assessments” then they must be covered.
The requirements also apply to:
“items and services furnished to an individual during healthcare provider office visits (including in-person visits and telehealth visits), urgent care center visits and emergency room visits that result in an order for or administration of an in vitro diagnostic product, but only to the extent that the items and services relate to the furnishing or administration of the product or to the evaluation of the individual for purposes of determining the need of the individual for that product.”
Plans are encouraged to implement (and document) policies and procedures that protect participants from inappropriate cost sharing. Similarly, plans are encouraged to provide information regarding providers and their rates to participants to minimize the risk that providers charge too much for these items and services.
In addition to testing, the FAQs also cover preventative services. Plans and issuers are reminded that the CARES Act requires that they provide coverage without cost sharing for all COVID-19 vaccines that have been recommended by the federal government as well as their administration. Plans and issuers must cover these preventive services without cost sharing starting no later than 15 business days (not including weekends or holidays) after the date the United States Preventive Services Task Force (USPSTF) or the Advisory Committee on Immunization Practices of the CDC (ACIP) makes an applicable recommendation regarding a qualifying coronavirus preventive service. Plans and issuers must cover these vaccines regardless of how the service is billed or how many shots it takes to complete the vaccination regimen. The FAQs also point out that the vaccines must be covered even if the recipient received it “out of turn” (that is, if the recipient is not considered a priority recipient, such as a person with high risk of complications if they contract COVID-19).
The FAQs also remind plans and issuers that the DOL will not take enforcement action if they implement these requirements without providing participants 60-days' advance notice of the changes, as required by the ACA SBC provision. However, plans and issuers must provide such notice to participants as soon as reasonably practicable.
Finally, the FAQs stress that employers may offer COVID-19 testing and vaccinations through an EAP, if it meets certain requirements. These services are not considered excepted benefits if they are “significant.” Benefits are considered significant based on the nature of the medical care, and the amount, scope and duration of covered services. However, the FAQs state:
“An EAP will not be considered to provide benefits that are significant solely because it offers benefits for COVID-19 vaccines and their administration (including when offered in combination with benefits for diagnosis and testing for COVID-19). However, there must be no cost sharing under the EAP for benefits under the EAP to constitute excepted benefits and the EAP must also comply with other applicable requirements.”
Employers can also provide COVID-19 vaccines through on-site medical clinics under all circumstances.
Employers should be aware of these clarifications of the FFCRA and CARES Act requirements.
FAQS about FFCRA and CARES Act Implementation, Part 44 »