In our previous alert, we outlined how the end of the PHE will affect group health plans. In other words, what could change with regards to coverage of COVID-19 diagnosis, testing and other related services.

In that article, we closed with a statement expressing our desire to get specific guidance from the agencies before the end of the PHE which is May 11, 2023. In welcome news, this guidance was issued on March 29 as FAQs Part 58 and April 13 as FAQs Part 59.

The Departments state they have issued these most recent FAQs to “clarify how the COVID-19 coverage and payment requirements under the FFCRA and CARES Act will change when the PHE ends.”.

Amongst other provisions tied to the PHE and National Emergency, the FAQs specifically point out that group health plans are not required to provide coverage for items and services related to diagnostic testing for COVID-19 that are incurred after the end of the PHE.

IMA comment: while it will no longer be required by federal law, group health plans may choose to keep these coverages in place. It’s also important to note that certain state laws have extended these coverage requirements beyond the PHE.

FAQ Q5 clarifies the outbreak period related to the end of the COVID-19 National Emergency along with examples. To review all FAQs, click here.

As a reminder, fully insured group health plans may be subject to specific state laws keeping these plan requirements in place, notably CA which we wrote about here.

What does this mean for an employer’s group health plan?

For self-insured ERISA group health plans, only federal law applies, which means the Plan sponsor should connect with their TPA to confirm desired plan design changes after May 11, 2023.

For CA based fully insured group health plans, state law requires an extension of COVID era protections. Specifically, CA SB 510 means that carriers will have to continue to cover COVID-19 diagnostic and screening tests without cost-sharing or other utilization management requirements.

Additionally, CA SB 1473 means that carriers must cover therapeutics, in and out of network, as well. At the end of six months after the PHE, carriers will only be obligated to cover the cost share of these services in-network.

For CA based fully insured plan, the plan sponsor should watch for carrier communication regarding plan impact due to the end of the PHE.

While every effort has been taken in compiling this information to ensure that its contents are totally accurate, neither the publisher nor the author can accept liability for any inaccuracies or changed circumstances of any information herein or for the consequences of any reliance placed upon it. This publication is distributed on the understanding that the publisher is not engaged in rendering legal, accounting or other professional advice or services. Readers should always seek professional advice before entering into any commitments.