TEN HIGHLIGHTS ABOUT COVID CLAIMS PROCESSING

Ten Highlights about COVID Claims Processing

The U.S. Department of Labor, the U.S. Department of Health and Human Services, and the U.S. Department of the Treasury have provided additional information by issuing FAQs Part 43 to help in the implementation of new federal laws and other health coverage issues related to COVID-19. We’ve collected some of the highlights below.

1. Plans and issuers are required to cover, without member cost sharing, COVID-19 tests intended for at-home testing, when the test is ordered by an attending healthcare provider.
2. There is no federal requirement for plans and issuers to cover COVID-19 testing for surveillance or employment purposes.
3. Plans and issuers are required to cover each test without member cost sharing if an individual receives multiple diagnostic tests for COVID-19, as well as other applicable items and services, provided the tests are diagnostic and medically appropriate for the individual, as determined by an attending healthcare provider in accordance with current accepted standards of medical practice.
4. COVID-19 testing will be reimbursed at either a negotiated rate or an amount that equals the cash price for such service that is listed by the provider on a public website. In either case, the amount the plan or issuer reimburses the provider constitutes payment in full for the test, with no cost sharing to the individual or other balance due. Therefore, the statute generally precludes balance billing or COVID-19 testing. However, the requirement to reimburse a provider an amount that equals the cash price of a COVID-19 test is contingent upon the provider making public the cash price for the test.
5. The plan or issuer may seek to negotiate a rate with the provider if a provider has not made the cash price of a COVID-19 diagnostic test available on a public website and the plan or issuer does not have a negotiated rate with the provider. (Federal law does not address the amount to be reimbursed if a provider has not made public the cash price for a test and the plan or issuer and the provider cannot agree upon a rate that the provider will accept as payment in full.)
6. The plan or issuer must reimburse an out-of-network provider of COVID-19 testing an amount that equals the cash price for the service listed by the provider on a public website if an individual receives a COVID-19 test in an emergency department of an out-of-network hospital, or the plan or issuer may negotiate a rate that is lower than the cash price.
7. Temporary relief from the federal government has allowed plans and issuers to make changes to coverage to increase benefits, or reduce or eliminate cost sharing, for the diagnosis and treatment of COVID-19 or for telehealth and other remote care services more quickly than they would otherwise be able to under current law.
   
   Upon the expiration of the public health emergency related to COVID-19, a plan or issuer can revoke these changes and satisfy its obligation to provide advance notice of a material modification under the Public Health Service Act and its implementing regulations with respect to a participant, beneficiary, or enrollee if the plan or issuer had:
   • Previously notified the participant, beneficiary, or enrollee of the general duration of the additional benefits coverage or reduced cost sharing, such as that the increased coverage applies only during the COVID-19 public health emergency.
   • OR notifies the participant, beneficiary, or enrollee of the general duration of the additional benefits or reduced cost sharing within a reasonable timeframe in advance of the reversal of the changes.
8. In light of the COVID-19 pandemic, a large employer may offer coverage only for telehealth and other remote care services to employees who are not eligible for any other group health plan offered by the employer.
9. A grandfathered plan that adds benefits or reduces or eliminates cost-sharing requirements for the diagnosis and treatment of COVID-19 or for telehealth and other remote care services during the COVID-19 public health or national emergency period will not lose its grandfather status solely because it later reverses these changes upon the expiration of the COVID-19 emergency period.
10. When performing the “substantially all” and “predominant” tests for financial requirements and quantitative treatment limitations under the Mental health Parity and Addiction Equity Act regulations, plans and issuers may disregard benefits for items and services required to be covered without cost sharing under the Families First Coronavirus Response Act.