On January 10, 2022, the Department of Labor issued FAQ Part 51, which provides new guidance on compliance with the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES).The new guidance includes a coverage requirement for insurance plans, including self-funded health plans for over-the-counter (OTC) or at home COVID-19 test kits.
Effective January 15, 2022, this testing must be covered with no member cost-sharing, regardless of whether the provider or retail pharmacy is part of any preferred provider network. In line with prior guidance, the plan may not institute any medical management requirements, such as prior authorizations. COVID-19 testing also no longer needs to be ordered by a health care provider, as previous guidance indicated.
If the plan covers these tests with no member cost-sharing at a pharmacy (through the prescription drug or mail order programs), the member won’t need to submit a claim manually for reimbursement. The plan is then eligible for a safe harbor allowing a limit of $12 per test or the price of the test, whichever is lower, to apply to non-preferred provider charges. Additionally, under a second safe harbor, the plan can limit testing to 8 OTC tests per month per member. (Please note, these limitations cannot be applied if the plan requires that the member purchase the test out-of-pocket and submit to the plan for reimbursement.)
The FAQ goes on to state that health plans are not required to cover these tests if they are for “employment purposes.” However, the pharmacy and the plan may not know the circumstances for which a test is needed, making this aspect difficult to monitor.
These additional requirements will remain in effect through the duration of the Public Health Emergency, which is currently set to expire this month. However, the Public Health Emergency may be extended every 90 days, and we anticipate this extension to occur.
Amendments to plan documents will not be necessary based on this updated guidance. Previous amendments containing the FFCRA and CARES requirements are sufficient to encompass this new material.
COVID-19 test kits are very difficult to obtain, and this requirement is likely to make that situation even worse. MedBen will also be releasing information from our pharmacy benefit managers as it becomes available.
Although not related to COVID-19, the FAQ also discusses future changes to the A/B recommendations under the United States Preventive Services Task Force. These changes will not become effective until the first plan year following May 1, 2022. Additional information will be provided in a future MedBen e-briefs.