CMS Issues FAQs on Essential Health Benefits and the Coronavirus

March 17, 2020

On March 12, 2020, CMS provided a set of FAQs that discusses the designation of COVID-19 treatment as an essential health benefit (EHB). As background, under the ACA, plans may not impose annual or lifetime limits on essential health benefits.

The FAQs address three questions:

  • Question and answer 1 confirms that the diagnosis and treatment of COVID-19 would be considered essential health benefits. However, each plan may determine the exact coverage details and any cost-sharing amounts that would apply to those services.
  • Question and answer 2 discusses whether COVID-19-related isolation or quarantine would be treated as EHB. On this issue, CMS confirms that hospitalizations for COVID-19 treatment would be considered an EHB. However, self-imposed isolation or quarantine at home is not considered a medical benefit, and therefore would not be covered as an EHB. Keep in mind, though, that medical benefits provided at home that are required by a medical provider (through home health care or telemedicine) would be covered as EHB.
  • Question and answer 3 provides that when a COVID-19 vaccine becomes available, it would be covered without cost sharing, pursuant to the ACA’s preventive care mandate. While such a vaccine would generally not be required to be provided without cost sharing until 12 months after the Advisory Committee on Immunization Practices of the CDC recommends them, CMS indicates that plans may voluntarily choose to provide the vaccine with or without cost sharing prior to that date. The answer also indicates that a participant with a plan that does not cover the vaccine may use the plan’s drug exceptions process to request that the vaccine be covered under the plan.

Employers should consider this guidance as they provide coverage to participants who may be diagnosed with and treated for COVID-19.

FAQs on Essential Health Benefit Coverage and the Coronavirus »