Essential Health Benefit Coverage (Coronavirus and the Law)

The Centers for Medicare & Medicaid Services Issues FAQs on Essential Health Benefit Coverage and the Coronavirus

On March 12, 2020, the Centers for Medicare & Medicaid Services (CMS) posted three Frequently Asked Questions (FAQ) on Essential Health Benefits (EHB) Coverage (pdf) in response to the 2019 coronavirus (COVID-19) outbreak.

The FAQs detail 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 FAQs are intended to clarify which COVID-19-related services, including testing, isolation/quarantine, and vaccination, are covered as EHBs in these markets.

FAQ 1 provides that EHBs currently include coverage for the diagnosis and treatment of COVID-19. However, CMS adds: “Exact coverage details, however, for individual services may vary plan by plan, and some plans may require prior authorization before these services are covered.”

FAQ 2 explains that isolation and quarantine for the diagnosis of COVID-19 are covered as EHBs. CMS still directs individuals to check the exact coverage requirements of their plan. Quarantine outside of a hospital setting is not a medical benefit, but home health care or telemedicine are covered benefits.

FAQ 3 states that when a COVID-19 vaccine is available, it will be covered as an EHB, and it will be available without cost-sharing. CMS notes that plans are not required to cover any vaccine until the beginning of the plan year that begins 12 months after the CDC recommends the vaccine.

The employee benefits attorneys of the Tax Group at Woods Rogers will continue to monitor updates from CMS on COVID-19 matters.