COVID-19 Testing

Are Group Health Insurance Plans Required to Cover All COVID-19 Tests?

On June 23, 2020, the Departments of Labor, Treasury, and Health and Human Services released answers to this and other frequently asked questions (FAQs) regarding COVID-19 services impacted by the Families First Coronavirus Response Act (FFCRA) and CARES Act.

Enacted on March 18, 2020, the FFCRA generally requires group health plans and issuers of group or individual health insurance coverage to provide certain benefits related to testing for COVID-19 without imposing any cost-sharing, prior authorization or other medical management requirements.

The CARES Act, enacted on March 27, 2020, amended the FFCRA to include a broader range of diagnostic items and services that plans and insurance issuers must cover at no cost. It generally requires plans and insurance issuers to reimburse any provider of COVID-19 diagnostic testing an amount that equals the negotiated rate or the cash price for such service.

Overall, the new FAQs address key issues for health plan sponsors and insurers working to implement federal requirements related to COVID-19, including that they are not required to cover COVID-19 tests in all situations. The new information also clarifies the following:

  • Group health plans and insurers are not required to cover COVID-19 tests for employment purposes or public health monitoring. The requirement to cover this service without cost-sharing applies only to tests intended for the diagnosis or treatment of COVID-19 as determined by a person’s attending healthcare provider.
  • Only COVID-19 tests that meet federal standards must be covered at no cost by group health plans and insurers. Plan sponsors can consult the Federal Food and Drug Administration website to determine if a specific test is covered by the law.
  • Group health plans must cover COVID-19 tests intended for at-home testing, provided the test meets government standards and is ordered by an attending healthcare provider.
  • There is no limit on the number of tests that must be covered without cost-sharing, provided they are deemed medically appropriate by an attending healthcare provider.
  • Health plans and insurers must provide no-cost coverage for services delivered during in-person, telehealth, urgent care center and emergency room visits that result in an order for or administration of a COVID-19 diagnostic test.

The recently-released FAQ answers also provide information regarding rules applicable to Summary of Benefits and Coverage notice requirements for plan sponsors; how employers may offer telehealth and remote-care services to employees who are not eligible for a group health plan; what cost-sharing requirements may be applied to mental health and substance use disorder benefits; and waiving requirements for plan participants to earn a reward under a health-contingent wellness program.

Pacific Federal is a subsidiary of Zenith American Solutions.