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Coronavirus vaccine

Federal regulators have issued rules supplying the first interpretive gloss on the group health plan coverage mandate, imposed by Congressional legislation last spring, to provide coronavirus vaccines with no cost sharing.

Consistent with the legislation, the new regulations require non-grandfathered group health plans to provide coverage of a coronavirus immunization within 15 business days after the vaccine is added to the list of preventive services recommended by the United States Preventive Services Task Force (USPSTF) or the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). A vaccine is embraced by the mandate even it is not listed for routine use on the immunization schedules of the CDC.

Plans sponsors likely will not be able to timely identify specific vaccines in a benefits schedule or amendment to a benefit schedule, and will simply want to confirm with their medical insurance carrier or third-party claims administrator (TPA) that the carrier and TPA are able to implement and administer coverage, within that aggressive timeframe, of any vaccine embraced by the federal mandate.

Lockton comment: The 15-day window to implement coverage for a vaccine is a dramatic acceleration of the timeline to which plans are accustomed when the USPSTF adopts a new preventive services recommendation. Under the Affordable Care Act, plans are required to implement coverage for certain newly recommended preventive services by the first day of the plan year beginning on or after one year after the recommendation is adopted.

Like the similar mandate that plans cover nearly all coronavirus testing, non-grandfathered plans must cover the recommended vaccine without cost sharing whether delivered by an in-network or out-of-network medical provider. Also, the office visit (unless the healthcare provider bills separately for the office visit), specimen collection, test and vaccine and the cost of the vaccine’s administration must all be covered. The coronavirus testing mandate will eventually expire when the end of the public health emergency (PHE) is declared. However, all non-grandfathered plans must continue to cover the coronavirus vaccine when one becomes available even after the PHE expires.

Lockton comment: See our prior alert on the coronavirus testing mandates that apply to all group plans whether insured, self-insured, grandfathered (under the ACA) or non-grandfathered.

The recent regulations also flesh out disclosure requirements on medical providers administering coronavirus testing. Current law requires group plans to pay, for coronavirus testing, either a negotiated rate or the provider’s cash price (essentially, the price charged to someone without insurance coverage), which providers are required to publicly disclose.

This cash price must be posted on the provider’s internet site. If the provider does not have its own website, it must post the price in its physical locations (if applicable). If the provider has multiple locations that impose varying costs, all must be posted and provide a written notice of the cost within two business days, if requested. Importantly, the rules specifically prohibit the use of email for purposes of providing written notice of the cash price.

Lockton comment: Because a group plan is required to pay an out-of-network provider that provider’s cash price for testing (unless the plan negotiates some different rate), plans need to know what the cash price is. If the plan won’t pay because it does not know how much to pay, there is a danger the insured could be balance billed by the provider. To discourage this, the Department of Health and Human Services has the authority to sanction a provider that fails to meet the cash price disclosure requirement.

Next steps

Many group plans provide coverage for mandated preventive care, as recommended by the USPSTF, without precisely listing that care. Such language may incorporate into the plan, by reference, coverage of a coronavirus vaccine. But if you are concerned your plan lacks the adequate language to provide for the mandated vaccine testing, your Lockton account service team can provide a model amendment that addresses both the testing and vaccine mandates.