CMS FAQs on Essential Health Benefits and COVID-19

CMS FAQs on Essential Health Benefits and COVID-19

The Centers for Medicare & Medicaid Services (CMS) released a list of frequently asked questions (FAQs) on Essential Health Benefit (EHB) coverage and the Coronavirus (COVID-19). Under the Affordable Care Act (ACA), EHB reflects the scope of benefits covered by a typical employer and covers at least 10 specified categories of items and services.

CMS’ FAQs:

1.Does EHB currently include coverage for the diagnosis and treatment of 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 (QHPs) purchased on the Exchanges, must provide coverage for 10 categories of EHB. These 10 categories include, among other things, hospitalization and laboratory services. Under current regulations, each state and the District of Columbia generally determines the specific benefits that plans in that state must cover within the 10 EHB categories. This standard set of state-determined benefits is called the EHB-benchmark plan. All 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of COVID-19.

Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and that they will waive any cost-sharing that would otherwise apply to the tests. Furthermore, many states are encouraging their issuers to cover a variety of COVID-19-related services, including testing and treatment, without cost-sharing. Other states have announced that health plans must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing.

2.Is isolation and quarantine for the diagnosis of COVID-19 covered as EHB?
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 apply other limitations. Quarantine outside of a hospital setting (such as at home) is not a medical benefit, nor is it required as EHB. However, other medical benefits that occur in the home may be covered as EHB if they are required by and provided under the supervision of a medical provider (such as home health care or telemedicine), but this may depend on prior authorization or be subject to cost-sharing or other limitations.

3.When a COVID-19 vaccine is available, will it be covered as EHB, and will issuers be permitted to require cost-sharing?
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 any applicable deductible is met, if the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, plans are not required to cover a new vaccine until the beginning of the plan year that is 12 months after ACIP issues a recommendation for it. 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.

Takeaways:

  • EHB generally includes coverage for the diagnosis and treatment of COVID-19.
  • All EHB-benchmark plans cover medically necessary hospitalizations, including isolation and quarantine.
  • A COVID-19 vaccine does not currently exist. Plans are not required to cover any new vaccine until the beginning of the plan year, 12 months after the CDC recommends it. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost-sharing, prior to that date.

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