Coverage for COVID-19 Testing and Vaccination

[LOGO] State of Utah SPENCER J. COX Governor DEIDRE M. HENDERSON Lieutenant Governor Insurance Department JONATHAN T. PIKE Insurance Commissioner # BULLETIN 2021-1 TO: Insurers Offering Health Insurance Coverage FROM: Jonathan T. Pike, Utah Insurance Commissioner DATE: April 14, 2021 Subject: Coverage for COVID-19 Testing and Vaccination The Utah Insurance Department issues this Bulletin to provide health insurers updated guidance concerning the federal requirements for coverage of COVID-19 testing and vaccination as required by the Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Additional resources available: - The Affordable Care Act Implementation FAQs Parts 42, 43, and 44, available at: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/aca-implementation-faqs and https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs - Centers for Medicare & Medicaid Services Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans, available at: https://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf Highlights of the most recent guidance include: 1. Diagnostic testing of asymptomatic individuals without a known or suspected exposure. Testing must be covered without cost sharing, prior authorization, or other medical management requirements when the purpose of the testing is for individualized diagnosis or treatment of COVID-19. Coverage is not required for public health surveillance or employment purposes. However, to the extent not inconsistent with the FFCRA's prohibition on medical management, an insurer may continue to employ programs designed to detect and address fraud and abuse. 2. Tests provided through state or locally administered testing sites. A provider acting within the scope of their license or authorization can make an individualized assessment regarding COVID-19 testing. An insurer is required to cover tests received from a licensed or authorized provider, including from a state or a locally administered site. An insurer must assume the test reflects an "individualized clinical assessment." There is no 4315 South 2700 West, Suite 2300, Taylorsville, Utah 84129 • Office (801) 957-9200 • Facsimile (385) 465-6047 • insurance.utah.gov distinction between point-of-care and other tests, all COVID-19 diagnostic tests must be covered. 3. **Covered Items and Services Associated with Diagnostic Testing.** An insurer must provide coverage for items and services furnished during an office visit (including in-person visits and telehealth visits), urgent care center, and emergency room visits that result in the administration of an in vitro diagnostic product. Claims processing systems should be maintained in ways to protect an insured from inappropriate cost sharing. 4. **Providers Not Complying with the CARES Act Related to Cash Pricing.** An insurer who detects possible violations with the cash price posting requirements may report violations to COVID19CashPrice@cms.hhs.gov. 5. **COVID-19 Vaccine Coverage and Associated Administration.** All COVID-19 vaccines that qualify as a coronavirus preventive service must be covered without cost sharing regardless of how the administration is billed, or the number of doses needed to be considered to be a complete vaccination. This includes the administration of an immunization where the federal government pays for the preventive immunization. 6. **Eligibility of Individuals Prioritized for Vaccination While Vaccine is Limited.** An insurer should not communicate that coverage is limited to only individuals recommended for early vaccination based on state and local plans for allocation of initial doses of the vaccine or categories of individuals prioritized for vaccination. An insurer with questions related to this Bulletin are advised to contact the Health and Life Division at health.uid@utah.gov. DATED this 14th day of April 2021. Jonathan T. Pike Insurance Commissioner