Working Together

On March 12, 2020, the Center for Medicare & Medicaid Services Center for Consumer Information & Insurance Oversight issued an FAQ regarding coverage for diagnosis and treatment of COVID-19 under the Affordable Care Act. CMS FAQ re EHBs  The three questions addressed in the CMS FAQ re EHBs are:

• Do Essential Health Benefits (EHBs) currently include coverage for the diagnosis and treatment of COVID-19?
• Are isolation and quarantine for the diagnosis of COVID-19 covered as EHBs?
• When a COVID-19 vaccine is available, will it be covered as an EHB, and will issuers be permitted to require cost-sharing?

CMS states that coverage for diagnosis and treatment of COVID-19 is an EHB.  The exact coverage details and cost-sharing amounts for individual services may vary by plan.  Some plans may require prior authorization before the services are covered.  Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and that cost-sharing for such tests will be waived.

CMS notes that there are 10 categories of EHBs including hospitalization and laboratory services.  However, each state and the District of Columbia are empowered generally to determine which services must be covered under each EHB category.  Currently, all states’ and the District of Columbia’s standard set of EHB services provide for coverage for the diagnosis and treatment of COVID-19.

Medically necessary hospitalizations are covered EHBs including medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission.  The cost-sharing and specific coverage limitations associated with such coverage will vary from plan to plan and prior authorization may be required.

Quarantine outside a hospital is not an EHB even if the quarantine is due to a COVID-19 diagnosis.  However, if home health care or telemedicine are required by and under the supervision of a medical provider, those services may be EHBs.  The plan will control whether prior authorization and cost-sharing will be required in connection with these services. The CMS FAQ re EHBs discusses the process for making any new vaccine an EHB not subject to cost-sharing. Under the current process, a plan could wait up to 12 months after approval as a “no cost sharing vaccine” before covering an approved new vaccine without cost sharing.  CMS indicates that many plans voluntarily choose to cover a new vaccine, with or without cost sharing, prior to the end of the 12-month delay period.