An Overview of the FFCRA, CARES Act Coronavirus Testing Rules

CMS has issued guidance for private health plans regarding coverage for coronavirus diagnostic testing and relevant products and procedures.

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“It is critical that Americans have peace of mind knowing that cost won’t be a barrier to testing during this national public health emergency,” said CMS Administrator Seema Verma in the press release. “Today’s action under the leadership of President Trump allows millions of Americans to access the vital health services they need to fight COVID-19, including antibody testing once it becomes widely available.”

According to the CMS guidance, private health plans must now cover diagnostic testing as well as relevant tasks and medical equipment. This means that they cannot place any cost-sharing, prior authorization, or medical management stipulations on these services or products.

Covered procedures and items include

• Urgent care visits
• Emergency department visits
• Telehealth visits
• In-person  office visits
• FDA-authorized coronavirus tests
• Coronavirus tests for which developers have requested emergency authorization
• State-developed and state-authorized coronavirus tests
• Coronavirus antibody testing

Antibody testing looks at the antibody activity in a patient’s blood to detect whether they are fighting a coronavirus infection.

Coronavirus antibody testing is not yet widely available. However, multiple pharmaceutical companies and organizations—including Pfizer and The Bill and Melinda Gates Foundation—are launching initiatives and partnerships to explore the potential for antibody testing.

Both plans on the group health insurance market and the individual health insurance market must comply with the coverage regulations. This includes self-insured group health plans and student health insurance coverage.

This covers a wide swath of the insured population. However, there are exceptions.

Short-term limited duration plans do not have to comply. Group health plans that fail to cover at least two not current employees, such as plans for retirees only, are also excepted.

There are also exceptions for which specific benefits and procedures plans are required to cover.

Plans may not have to cover procedures that fall under excepted benefits, depending on the procedure and the category of excepted benefit. Non-healthcare coverage benefits, including all on-site medical clinics, are exempt from coverage. For limited excepted benefits to be exempt, four requirements must apply. The benefit must be non-medical. It also cannot be coordinated with another group health plan’s benefits, must not impose cost-sharing, and must not require that employees pay a premium or contribute toward the excepted benefit.

Employers may choose to cover coronavirus-related benefits and testing that fall under any of these categories.

The guidance clarified how to approach out-of-network reimbursement.

If an out-of-network provider delivers the service, the payer must either match the reimbursement service rate which the provider names on its website or the payer may negotiate the provider’s stated rate.

In light of all of the changes regarding coverage and telehealth procedures, the guidance noted that plans have more grace in issuing notices to members regarding plan changes when they add coronavirus-related benefits or reduce or eliminate coronavirus testing cost-sharing.

Normally, such changes would require 60 days’ advance notice to enrollees. Instead, HHS is allowing states and plans to send out an alert to members and beneficiaries “as soon as reasonably practicable.”

However, this leniency does not extend to other plan activities.

“The Departments would continue to take enforcement action against any health insurance issuer or plan that attempts to limit or eliminate other benefits, or to increase cost-sharing, to offset the costs of increasing the generosity of benefits related to the diagnosis and/or treatment of COVID19,” the guidance stated.

The policies descended from the first and second coronavirus stimulus packages, the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid Relief, and Economic Security (CARES) Act, which went into effect on March 18 and March 27, 2020, respectively.

States may require additional requirements or standards. Health plans should be well-acquainted with their individual states’ policies in addition to the effects of the FFCRA and CARES Act.

These policies will remain in effect until the public health emergency lifts.