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CMS Issues Guidance to Health Plans for COVID-19 Vaccines

The interim final rule of November 6, 2020 addresses some additional guidance regarding various components of the CARES Act.

Specific to benefits and insurance, the joint departments, e.g. Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS); Internal Revenue Service (IRS), Department of the Treasury; Employee Benefits Security Administration (EBSA), Department of Labor (DOL), address:

  • The public disclosure of costs associated with diagnostic tests;
  • The timeframe for non-grandfathered group health plans offering group or individual coverage to cover certain COVID-related preventive services with no cost-share, including vaccines; and
  • Flexibilities to the public notice requirements regarding State Innovation Waivers of Section 1332 of the Patient Protection and Affordable Care Act (PPACA) during the public emergency.

Background/Timeline

  • On January 31, 2020, the Secretary of Health and Human Services (HHS) determines that a public health emergency (PHE) exists for the United States, one day after the World Health Organization (WHO) declares the COVID-19 outbreak as a “Public Health Emergency of International Concern."
  • The WHO declares COVID-19 to be a pandemic on March 11, 2020 and President Trump responds on March 13, 2020 by declaring the pandemic a national emergency
  • Through its monitoring of the situation, the HHS Secretary declares that a PHE exists effective January 27, 2020
  • To date, there is no projection or issue of an end date to the PHE
  • The Administration establishes Operation Warp Speed in partnership with the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the Biomedical Advanced Research and Development Authority (BARDA) to ensure Americans have access to a vaccine

New Developments

These rules are effective as of November 2, 2020 and through the end of the public emergency. Comments to these interim final rules are due January 4, 2021.

The interim final rules require the following:

  1. Recommended immunizations (vaccines) that are qualifying coronavirus preventive services

    • During the PHE for COVID-19, group health plans and health insurance issuers of group or individual insurance coverage must cover these services with no cost sharing for both in-network and out-of-network providers ( for out-of-network providers, issuers may reimburse up to an allowed amount that is reasonable when comparing to prevailing market rates
    • Plans must provide coverage within 15 business days after the date the United States Preventive Services Task Force (USPSTF) or the Advisory Committee on Immunization Practices of the CDC (ACIP) recommends the preventive service
    • Providers who receive the vaccine free from the federal government cannot seek reimbursement from consumers
    • Providers may submit a claim to the provider relief fund for patients without health coverage or for whom their plan does not cover preventive care, e.g. short term limited duration plans, grandfathered plans, or excepted benefits
  2. Cash prices for COVID-19 diagnostic testing

    • The CARES Act requires providers to post their cash prices to the public
      • Must be available electronically via the internet
      • Information, or a link to it, must appear in a conspicuous place on the provider’s website
      • Information must be easily accessible, e.g. free of charge, without requirement of a user account or password, without having to submit personal identifiable information
      • Providers must include the following terms on the site: price, cost, test, COVID, and coronavirus
      • Providers who do not own their website must make information available, in writing, within two business days of the request and on a sign posted at their location offering the test
      • Notice must include a plain-language description of the diagnostic test, billing code, cash price, and any other necessary information to help the public identify the connection between the cash price and the actual test
    • The interim final rule gives CMS discretion to act against providers who do not comply, including issuing of written warnings, development of corrective action plans, and civil or monetary penalties

    Next Steps

    • Employers with self-insured health plans should speak with their administrator to prepare for these changes, modify their plan document accordingly, and make appropriate communications to plan participants.
    • Employers who offer fully-insurance health plans through a health insurance issuer, be on the lookout for communications on coverage for vaccines and communicate information to plan participants

    The CMS COVID-19 toolkit provides additional information.

    Looking for the latest developments on this evolving pandemic? Visit OneDigital’s Coronavirus Hub for practical solutions that are actionable, timely and helpful in shaping workforce decision-making.

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