COVID-19-Related Benefits Compliance Resources Available

January 19, 2022

The Benefits Compliance team provides several resources that are available for assistance during the COVID-19 crisis. Information presented through our resources is subject to change pending additional guidance from the DOL, IRS or other state or federal regulatory agencies.

FAQs on Benefits and Compliance and COVID-19

Families First Coronavirus Response Act (FFCRA) Flowchart

COVID-19 State Quick Reference Chart

DOL Issues COVID-19 Relief via Certain Notice Extensions for Employee Benefit Plans

Compliance Considerations on Insurance Carrier Refunds in the COVID-19 Environment

IRS Announces New Guidance for Section 125 Cafeteria Plans and Related High Deductible Health Plans and IHCRAs

Benefits Compliance COVID-19 Weekly Updates and FAQs Webinars
Refer to the NFP insights page for the archived webinars from March 24, March 31, April 7, April 14, April 21, April 28, May 5, May 12, May 19 and May 26, 2020.

COVID-19 – State Leave Provisions: New York

COVID-19 – State Leave Provisions: New Jersey

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FAQs Issued on Coverage of COVID-19 Diagnostic Testing and Preventive Services

January 19, 2022

On January 10, 2022, the DOL, HHS and the Treasury Department (the “departments”) issued guidance in the form of FAQs regarding new COVID-19 test requirements. Starting January 15, 2022, and effective until the end of the public health emergency, the guidance states that health insurance carriers and group health plans (including self-insured plans) must pay for over-the-counter (OTC) COVID-19 tests without cost-sharing, prior authorization or other medical management requirements. The departments produced this guidance under orders from the Biden administration. Under the FFCRA and the CARES Act, this guidance adds to the existing requirement that carriers and plans must pay for COVID-19 tests that a healthcare provider provides to participants, beneficiaries or enrollees (i.e., employees and their dependents covered by the employer’s group health plan).

COVID-19 Test Coverage Requirement
Six FAQs address the new COVID-19 test coverage requirement. At a high level, the FAQs state:

  • Coverage may (but is not required to) apply to tests purchased prior to January 15, 2022.
  • The plan can provide the coverage by reimbursing sellers of OTC COVID-19 tests directly (referred to as direct coverage) or by requiring covered employees and their dependents who purchase an OTC COVID-19 test to submit a claim for reimbursement to the plan. The departments strongly encourage but do not require direct coverage.
  • The requirement only applies to “diagnostic” OTC COVID-19 tests, such as PCR and antigen tests, in contrast to those not primarily intended for individualized diagnosis or treatment of COVID-19. That includes any FDA-approved at-home test, whether ordered in person or online.
  • Plans and carriers may limit the number of tests reimbursed to no less than eight OTC COVID-19 tests per covered individual per 30-day period (or per calendar month) if purchased without the involvement of a healthcare provider. There is no limit on the number of tests, including OTC COVID-19 tests, which plans and carriers must cover if a healthcare provider orders or administers them following an individualized clinical assessment.
  • Plans and carriers must accept all reimbursement claims submitted with valid receipts and must not unduly delay reimbursement.
  • The departments encourage plans and carriers to develop a network of convenient locations (e.g., pharmacies, stores, online retailers, etc.) for covered employees and their dependents – at the direct point of sale – to obtain tests with no upfront cost. If the plan or carrier has set up a network of preferred retailers, covered employees and their dependents who purchase a test outside that network are still entitled to reimbursement from the plan or carrier of up to $12 per individual test if they submit a valid receipt.
  • This requirement applies only to OTC COVID-19 tests purchased or obtained by employees covered by the employer’s group health plan and their dependents.

Each FAQ provides additional detail, as set forth below.

FAQ#1 asserts that the FFCRA provides the authority for this requirement. The FFCRA requires plans and carriers to cover the cost of COVID-19 tests without imposing any cost-sharing requirements, prior authorization or other medical management requirements. The FFCRA does not require plans and carriers to pay the sellers of these tests directly; rather, requiring covered employees and their dependents to pay for the tests and then submit a request for reimbursement is also acceptable. In any event, the requirement is no longer limited to tests provided because of an order from a healthcare provider — covered employees and their dependents can obtain a test on their own for any reason. This new guidance does not amend previous guidance stating that plans and carriers are not required to pay for tests that employees must take for employment purposes.

FAQ#2 creates a safe harbor for plans and carriers to satisfy this requirement. Under this safe harbor, a plan or carrier can provide coverage of OTC COVID-19 tests purchased by covered employees and their dependents by arranging for direct coverage of OTC COVID-19 tests through both its pharmacy network and a direct-to-consumer shipping program. The safe harbor allows plans and carriers that use it to limit reimbursement for OTC COVID-19 tests from non-preferred pharmacies or other retailers to no less than the actual price or $12 per test (whichever is lower). To use this safe harbor, the plan or issuer must take reasonable steps to ensure that covered employees and their dependents have adequate access to OTC COVID-19 tests through an adequate number of retail locations (including both in-person and online locations). A plan or issuer that is unable to meet the requirements of this safe harbor cannot deny coverage or impose cost-sharing (including setting limits on the amount of reimbursement for OTC COVID-19 tests) with respect to any OTC COVID-19 tests obtained by covered employees and their dependents, including those purchased from non-preferred sellers. Note that this safe harbor applies only to the requirement to provide coverage of OTC COVID-19 tests. Plans and carriers must continue to provide coverage for COVID-19 tests that a healthcare provider administers either directly or through a prescription, even when relying on this safe harbor.

FAQ#3 creates another safe harbor under which plans and carriers may set limits on the number of tests that a person can obtain because of this requirement. The departments will not act against a plan or issuer that limits the number of tests covered for each covered employee or their dependents to no less than eight tests per 30-day period (or per calendar month). It is important to note that the eight test per month limit applies to each covered employee and dependent (for example, an employee covering a spouse and two children could get 32 tests per month). In addition, the limit applies to each individual test, regardless of how the tests are packaged (e.g., two tests are often packaged in one box). While plans and carriers can apply an eight-test monthly limit, they must not limit covered employees and their dependents to a smaller number of these tests over a shorter period (for example, limiting individuals to four tests per 15-day period). However, they may set limits that are more generous. This safe harbor does not apply either to tests that a healthcare provider administers directly or through a prescription.

FAQ#4 allows plans and carriers to take reasonable steps to prevent, detect and address fraud and abuse when satisfying this requirement. Acceptable steps to take include an attestation requirement, such as a signature on a brief attestation document, that states the participant or their dependents purchased the OTC COVID-19 test for personal use, not for employment purposes; has not been (and will not be) reimbursed by another source; and is not for resale. In addition, plans and carriers can require covered employees and their dependents to provide reasonable documentation of proof of purchase with a claim for reimbursement for the cost of an OTC COVID-19 test. The guidance cautions that fraud and abuse programs are unreasonable if they require an individual to submit multiple documents or involve numerous steps that unduly delay access to or reimbursement for OTC COVID-19 tests by covered employees or their dependents.

FAQ#5 allows plans and carriers to provide education and information resources to support consumers seeking OTC COVID-19 testing if such resources clarify that the plan or carrier provides coverage for, including reimbursement of, all OTC COVID-19 tests. Such information includes guidance to help people access and effectively use OTC COVID-19 tests, and information to explain the differences between OTC COVID-19 tests and tests performed or ordered by a healthcare provider and/or processed in a laboratory. Plans and carriers can also provide information concerning the quality and reliability of various tests, including shelf life and expiration dates. Plans and carriers can also provide information to participants and their dependents about obtaining tests and obtaining reimbursement for tests they pay for out-of-pocket.

FAQ#6 establishes the requirement’s effective date as January 15, 2022. Plans and carriers may amend the terms of a plan or coverage as necessary to comply with these updates related to coverage of OTC COVID-19 tests without regard to otherwise applicable restrictions on mid-year changes to health insurance coverage.

Other ACA Requirements
The ACA requires plans and carriers to cover certain items or services without cost-sharing, including evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF). The next two FAQs in this guidance clarify certain services that are subject to this requirement.

FAQ#7 states that a plan or issuer must cover colonoscopies conducted after a positive non-invasive stool-based screening test or direct visualization screening test for colorectal cancer for individuals described in the USPSTF recommendation, without cost-sharing.

FAQ#8 states that plans and carriers must provide coverage for a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization test based on the new USPSTF recommendation, without cost-sharing, for plan or policy years beginning on or after May 31, 2022.

FAQ#9 states that the departments are actively investigating complaints that plans, carriers and pharmacy benefit managers are denying contraceptive coverage to participants, beneficiaries or enrollees in violation of the ACA.

Employer Takeaway
Employers should review this guidance and work closely with their carrier or TPA to develop a strategy and process to ensure compliance with the COVID-19 test coverage requirements and communicate with employees and the other guidance concerning the ACA. Further, employers should discuss with their carrier or TPA whether to set up direct coverage through a preferred pharmacy or retailer or require covered employees and their dependents to pay the cost upfront and reimburse it later.

DOL FAQs About Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief and Economic Security Act Implementation »
HHS Press Release »
CMS FAQ How to Get Your At-Home Over-The-Counter COVID-19 Test for Free »

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Supreme Court Halts Enforcement of Large Employer OSHA Vaccine ETS, but Allows Healthcare Worker Vaccine Mandate

January 19, 2022

On January 13, 2021, the US Supreme Court granted a stay of enforcement on the Occupational Safety and Health Administration (OSHA) Emergency Temporary Standard (ETS) vaccine mandate for employers who employ 100 or more workers. The Court did not decide on the merits of the case challenging the mandate; rather, it concluded that the parties challenging the mandate would likely succeed on the merits of the case, so a stay was appropriate. Accordingly, the government cannot enforce this mandate until the resolution of the pending litigation challenging it, which is currently in the US Court of Appeals for the Sixth Circuit. You can find more information on the ETS in the December 21, 2021, Compliance Corner article. The stay applies to the employer vaccine mandate, meaning employers do not have to comply with the OSHA ETS, at least for now.

Separately, the Supreme Court did not grant another request to stay a vaccine mandate relating to healthcare workers who work for entities that receive funds from Medicare or Medicaid. As a result, that mandate is now in effect. Employers that are healthcare providers should review their obligations under this mandate. See this January 4, 2022, Compliance Corner article for more information.

For employers with 100 or more workers, the OSHA ETS litigation could take some time, and it is possible that the Supreme Court will strike down the mandate if a party to the lawsuit appeals the ultimate decision of the Sixth Circuit. However, this stay does not prohibit employers from implementing their own vaccine mandate or testing policies, subject to reasonable accommodation requirements under the Americans with Disabilities Act and state law. Employers should consult with employment law counsel if they are considering their own vaccine and testing policies.

Supreme Court Opinion on Large Employer OSHA ETS »
Supreme Court Opinion on Healthcare Worker Vaccination Requirement »

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COVID-19-Related Benefits Compliance Resources Available

January 04, 2022

The Benefits Compliance team provides several resources that are available for assistance during the COVID-19 crisis. Information presented through our resources is subject to change pending additional guidance from the DOL, IRS or other state or federal regulatory agencies.

FAQs on Benefits and Compliance and COVID-19

Families First Coronavirus Response Act (FFCRA) Flowchart

COVID-19 State Quick Reference Chart

DOL Issues COVID-19 Relief via Certain Notice Extensions for Employee Benefit Plans

Compliance Considerations on Insurance Carrier Refunds in the COVID-19 Environment

IRS Announces New Guidance for Section 125 Cafeteria Plans and Related High Deductible Health Plans and IHCRAs

Benefits Compliance COVID-19 Weekly Updates and FAQs Webinars
Refer to the NFP insights page for the archived webinars from March 24, March 31, April 7, April 14, April 21, April 28, May 5, May 12, May 19 and May 26, 2020.

COVID-19 – State Leave Provisions: New York

COVID-19 – State Leave Provisions: New Jersey

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Supreme Court to Hear Oral Arguments Regarding Vaccine Mandates on January 7

January 04, 2022

On December 22, 2021, the Supreme Court announced that it will hear oral arguments regarding the CMS vaccine mandate for healthcare workers and the Occupational Safety and Health Administration (OSHA) Emergency Temporary Standard (ETS) mandate for employers who employ 100 or more workers.

CMS issued an interim final rule on November 5, 2021, requiring the staff of twenty-one types of Medicare and Medicaid healthcare providers to receive one vaccine by December 6, 2021, and to receive the second vaccine by January 4, 2022. More information on the specifics of this mandate can be found here. The interim final rule was immediately challenged in the courts, and it is currently subject to preliminary injunctions in 25 states. The agency asked the Supreme Court to take up the matter and, in the meantime, will enforce its mandate only in those states where no injunction applies. Note that there are new deadlines for complying with the CMS mandate: the first vaccine dose must be administered by January 27, 2022, and the second dose by February 28, 2022. More information on this decision (including a list of the states where the mandate does not currently apply) can be found here.

The OSHA ETS (imposed on employers with 100 or more employees) is currently in effect, as discussed in the December 21, 2021 article in Compliance Corner. As noted in that article, the agency announced that it would not issue citations for noncompliance with any requirements under the ETS until January 9, 2022. It will not issue citations for noncompliance with the standard’s testing requirements before February 9, 2022. The plaintiffs challenging this mandate appealed the most recent US Court of Appeals for the Sixth Circuit decision to the Supreme Court.

These mandates are expected to remain in force (subject to the parameters established by the respective agencies) until the Supreme Court issues a ruling. We will continue to provide updates as the cases develop.

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COVID-19-Related Benefits Compliance Resources Available

December 21, 2021

The Benefits Compliance team provides several resources that are available for assistance during the COVID-19 crisis. Information presented through our resources is subject to change pending additional guidance from the DOL, IRS, or other state or federal regulatory agencies.

FAQs on Benefits and Compliance and COVID-19

Families First Coronavirus Response Act (FFCRA) Flowchart

COVID-19 State Quick Reference Chart

DOL Issues COVID-19 Relief via Certain Notice Extensions for Employee Benefit Plans

Compliance Considerations on Insurance Carrier Refunds in the COVID-19 Environment

IRS Announces New Guidance for Section 125 Cafeteria Plans and Related High Deductible Health Plans, and IHCRAs

Benefits Compliance COVID-19 Weekly Updates and FAQs Webinars
Refer to the NFP insights page for the archived webinars from March 24, March 31, April 7, April 14, April 21, April 28, May 5, May 12, May 19 and May 26, 2020.

COVID-19 – State Leave Provisions: New York

COVID-19 – State Leave Provisions: New Jersey

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Court Reinstates COVID-19 Vaccine Mandate

December 21, 2021

On December 17, 2021, the US Court of Appeals for the Sixth Circuit lifted the stay on the enforcement of the Occupational Safety and Health Administration’s emergency temporary standard (ETS) on vaccination and testing. The ETS covers private employers with 100 or more employees. Although the court’s ruling was promptly appealed to the Supreme Court, for now, the mandate has been reinstated and is in full effect.

In response, the DOL announced that OSHA would delay the enforcement of the mandate to give employers time to comply. Accordingly, OSHA will not issue citations for noncompliance with any requirements under the ETS until January 9, 2022, and will not issue citations for noncompliance with the standard’s testing requirements before February 9, 2022. Our original article on the mandate can be found in the November 9, 2021, edition of Compliance Corner.

Note that separate vaccine mandates apply to federal contractors and healthcare providers, and those orders remain under court review, with enforcement suspended in the meantime.

Sixth Circuit Order on Emergency Motion to Dissolve Stay »
DOL Announcement »

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COVID-19-Related Benefits Compliance Resources Available

December 07, 2021

The Benefits Compliance team provides several resources that are available for assistance during the COVID-19 crisis. Information presented through our resources is subject to change pending additional guidance from the DOL, IRS, or other state or federal regulatory agencies.

FAQs on Benefits and Compliance and COVID-19

Families First Coronavirus Response Act (FFCRA) Flowchart

COVID-19 State Quick Reference Chart

DOL Issues COVID-19 Relief via Certain Notice Extensions for Employee Benefit Plans

Compliance Considerations on Insurance Carrier Refunds in the COVID-19 Environment

IRS Announces New Guidance for Section 125 Cafeteria Plans and Related High Deductible Health Plans, and IHCRAs

Benefits Compliance COVID-19 Weekly Updates and FAQs Webinars
Refer to the NFP insights page for the archived webinars from March 24, March 31, April 7, April 14, April 21, April 28, May 5, May 12, May 19 and May 26, 2020.

COVID-19 – State Leave Provisions: New York

COVID-19 – State Leave Provisions: New Jersey

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COVID-19-Related Benefits Compliance Resources Available

November 09, 2021

The Benefits Compliance team provides several resources that are available for assistance during the COVID-19 crisis. Information presented through our resources is subject to change pending additional guidance from the DOL, IRS, or other state or federal regulatory agencies.

FAQs on Benefits and Compliance and COVID-19

Families First Coronavirus Response Act (FFCRA) Flowchart

COVID-19 State Quick Reference Chart

DOL Issues COVID-19 Relief via Certain Notice Extensions for Employee Benefit Plans

Compliance Considerations on Insurance Carrier Refunds in the COVID-19 Environment

IRS Announces New Guidance for Section 125 Cafeteria Plans and Related High Deductible Health Plans, and IHCRAs

Benefits Compliance COVID-19 Weekly Updates and FAQs Webinars
Refer to the NFP insights page for the archived webinars from March 24, March 31, April 7, April 14, April 21, April 28, May 5, May 12, May 19, and May 26, 2020.

COVID-19 – State Leave Provisions: New York

COVID-19 – State Leave Provisions: New Jersey

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OSHA Issues COVID-19 Vaccine Mandate

November 09, 2021

The DOL’s Occupational Safety and Health Administration (OSHA), released its long-anticipated emergency temporary standard (ETS) requiring employers with a total of 100 or more employees to institute written mandatory vaccination policies for their employees. The ETS is effective November 5, 2021. The ETS pre-empts state law and regulation concerning COVID-19 vaccinations, testing and face coverings, unless the state has a plan that has been approved by the federal government.

Because this mandate primarily involves employment and labor law, employers should consult with legal counsel regarding employer compliance with the new requirements.

All employees (temporary, seasonal, part-time, full-time, remote workers) working in the US are counted for purposes of determining if an employer is subject to the ETS. Workers employed by a temporary staffing agency are counted by the agency, not the host employer. Employer size is determined on November 5, 2021. Once an employer is subject to the requirement due to size, they remain subject for the entire ETS period.

Covered employers must establish, implement and enforce the written vaccination policy, although they can provide their employees with the choice of either becoming fully vaccinated or providing proof of regular COVID-19 testing and wearing a face covering. Note that employers must provide reasonable accommodations for employees who cannot be vaccinated due to the vaccine being medically contraindicated or a disability, or when doing so conflicts with a sincerely held religious belief, practice or observance. Neither the vaccine mandate nor the testing applies to employees who do not report to a worksite with customers or other coworkers, or to employees who work exclusively outdoors.

In addition to the policy, employers subject to the ETS must provide all workers up to four hours of paid time, including travel time, for each of their primary vaccination doses received during normal work hours at the employee’s regular rate of pay. Employers must provide reasonable time and paid sick leave to each employee for recovery from side effects following any primary vaccination dose. Two days of paid sick leave is considered reasonable.

Employers must determine each employee’s vaccination status and maintain records of that status. Examples of acceptable proof of vaccination status include COVID-19 vaccination record cards, copies of records of immunization provided by a healthcare provider, and a signed attestation from the employee that they are vaccinated (if they cannot provide one of the other forms of proof). These vaccination records are confidential medical records, and the employer must maintain them accordingly.

Employees who are not fully vaccinated must be tested for COVID-19 at least weekly (if the worker is in the workplace at least once a week) or within seven days before returning to work (if the worker is away from the workplace for a week or longer). The ETS does not require employers to pay for testing, although other laws, regulations, collective bargaining agreements or other collectively negotiated agreements may require it. Employers are also not required to pay for face coverings.

If an employee tests positive for COVID-19 or receives a COVID-19 diagnosis, they must provide prompt notice to their employer. Employers must then remove the employee from the workplace, regardless of vaccination status. Employers must not allow them to return to work until they meet required criteria, which includes a negative COVID-19 test, meeting the CDC’s return to work criteria or a recommendation from a licensed healthcare provider.

Employers must comply with most requirements within 30 days of the effective date and with testing requirements within 60 days of the effective date. This means that the written policy, leave and face covering requirements must be in place by December 5, 2021. Employees must either be fully vaccinated or subjected to regular testing by January 4, 2022. Note that there is a 30-day comment period that began on the effective date as well. Comments submitted in that time will be considered by the agency and may lead to changes in the ETS.

Note that this ETS does not apply to government contractors, which are subject to their own mandates. The Biden administration issued an executive order that requires government contracts to include language instituting vaccine mandates for government contractors. This mandate applies to all employees working on or in connection with a government contract and requires them to be vaccinated. Although employers must provide reasonable accommodations, government contract employees do not have the option to be tested weekly instead of getting vaccinated. The original due date for vaccinations under this ETS was December 8, 2021, but that has been extended to January 4, 2022, to be in line with the other mandates. Information on this mandate can be found here.

In addition to the ETS, CMS issued an interim final rule (effective starting November 5, 2021) that applies to certain Medicare and Medicaid-certified providers and suppliers, which includes hospitals, home health agencies, and long-term care facilities. The rule requires staff of those providers and suppliers have their second dose of the vaccination by January 4, 2022 (although they are not required to complete the two week waiting period). The rule does not provide a weekly testing option. The rule can be found here.

Note: On November 6, 2021, the US Court of Appeals for the Fifth Circuit issued a stay on the enforcement of the ETS, citing “grave statutory and constitutional issues with the mandate.” This stay is the result of action brought by private actors and several states, including Texas, Louisiana and South Carolina, and is effective until the court takes further action. The federal government must file a response to the petitioners’ request for a permanent injunction by the end of the day on November 8, 2021. The order can be found here.

ETS (unpublished version) »
Fact Sheet »
FAQs »

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