CMS Issues Information Related to COVID–19 Individual and Small Group Market Insurance Coverage

March 2020 ~

CMS has issued a fact sheet detailing existing federal rules governing health coverage provided through the individual and small group insurance markets that apply to the diagnosis and treatment of COVID-19.

The following topics are covered in the COVID–19 Individual and Small Group Market Insurance Coverage Fact Sheet:

Diagnostics & Laboratory Services

Laboratory services are a category of Essential Health Benefits (EHB) that individual and small group market issuers are generally required by law to include in their benefit packages. However, whether any particular diagnostic or laboratory service is covered by a plan varies, and is based on the specific benchmark plan selected by each state and the terms of the plan. Large group market plans and self-insured plans are not subject to EHB coverage requirements.

Vaccines

If a vaccine is developed for COVID-19 and approved for use by the FDA, further guidance may be issued regarding whether the vaccine would need to be covered as a preventive service for which no cost sharing would be charged.

Hospitalization & Ambulatory Patient Services

Hospitalization, ambulatory patient, and emergency services are categories of EHB that individual and small group market issuers are generally required by law to include in their benefit packages. However, whether any particular hospitalization, ambulatory patient, or emergency service is covered by plans varies, and is based on the specific benchmark plan selected by each state and the terms of the plan. Large group market plans and self-insured plans are not subject to EHB coverage requirements.

Telehealth

Telehealth services or home health visits may already be covered by many health insurance companies.

Prescription Drugs

Prescription drugs are a category of EHB that individual and small group market issuers are generally required by law to include in their benefit packages. However, whether any particular prescription drug is covered by plans varies and is based on the specific benchmark plan selected by each state and the terms of the plan. Prior authorization for prescription drugs, including for any treatment for COVID-19 that may become available, may still apply. Plans and issuers may elect to apply prior authorization for treatment and or refills flexibly, as circumstances warrant. Large group market plans and self-insured plans are not required to cover EHBs, so coverage would depend on the terms of the plan.

Benefit and coverage details may vary by state and by plan. States may choose to work with plans and issuers to determine the coverage and cost-sharing parameters for COVID-19 related diagnoses, treatments, equipment, telehealth and home health services, and other related costs.

For more information related to COVID–19 individual and small group market insurance coverage, CMS suggests the following resources: HealthCare.gov, CDC.gov, and the National Association of Insurance Commissioners (NAIC) Coronavirus resource center.

Source(s): CMS Fact Sheet; Medicare Administrative Contractor (MAC) COVID-19 Test Pricing March 12, 2020;