On February 26, 2021, the Centers for Medicare & Medicaid Services ("CMS"), together with the U.S. Departments of Labor, Health and Human Services ("HHS"), and the Treasury, issued new guidance in the form of FAQs regarding the implementation of the Families First Coronavirus Response Act ("FFCRA"), the Coronavirus Aid, Relief, and Economic Security Act ("CARES Act"), and other health coverage issues related to COVID-19.  Notable FAQs relating to the coverage of COVID-19 diagnostic testing and vaccines are highlighted below.

Coverage for Testing by Plans:

The guidance provides that the FFCRA prohibits plans and issuers from using medical screening criteria to deny, or impose cost-sharing on, a claim for COVID-19 diagnostic testing of an asymptomatic individual with no known or suspected exposure to COVID-19.  More specifically, when an individual receives a COVID-19 diagnostic test from a licensed or authorized health care provider, a health plan "generally must assume that the receipt of the test reflects an 'individualized clinical assessment' and the test should be covered without cost-sharing, prior authorization, or other medical management requirements."  However, plans are not required to provide coverage for COVID-19 diagnostic testing for other purposes, including for public health surveillance or employment purposes.  In addition, the guidance makes clear that health care providers (not plans and issuers) are responsible for implementing any applicable state or local limits on COVID-19 diagnostic testing eligibility.

Coverage for Vaccines by Plans:

The guidance explains that plans and issuers are required to provide coverage, without cost-sharing, for all COVID-19 vaccines with a recommendation in effect from the Advisory Committee on Immunization Practices ("ACIP") of the Centers for Disease Control and Prevention ("CDC") or the United States Preventive Services Task Force ("USPSTF").  This coverage must begin no later than fifteen (15) business days (not including weekends or holidays) after the date the USPSTF or ACIP makes an applicable recommendation regarding a qualifying coronavirus preventive service.  In addition, the guidance clarifies that plans and issuers may not deny coverage for a COVID-19 vaccine administered to an individual who is not in a category recommended for early vaccination.  Thus, government prioritization does not affect the responsibility of plans and issuers to provide coverage, without cost-sharing, of COVID-19 immunizations in accordance with the vaccine-specific recommendations of ACIP.  The guidance also provides that plans and issuers must cover the vaccine administration fee, without cost-sharing, even when they are not billed for the vaccine (e.g., when a third party, such as the federal government, pays for the vaccine).

Lastly, the guidance highlights ways in which providers may seek federal reimbursement for costs incurred when administering COVID-19 diagnostic testing or a COVID-19 vaccine to uninsured individuals.  One such avenue is the Provider Relief Fund program.  This federal guidance clarifies that health care providers should be receiving compensation for the administration of COVID-19 tests and vaccines. 

Originally published on March 1, 2021

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