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Insurance Coverage and Coronavirus Testing

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Will My Insurance Cover the Cost of Coronavirus Testing?

As we continue to navigate through the effects of COVID-19, many questions arise when it comes to insurance coverage. Does your specific insurance cover testing? Does it cover treatment? How can I find out my coverage options? 

The short answer is it depends on your coverage. Health insurance coverage varies widely, depending on where you live and how you obtain your coverage. Almost half of Americans receive their insurance coverage from their employers. Those plans are managed by both the federal and state guidelines, which depend on the group size and whether or not the plans are self-insured or fully-insured. So how does Coronavirus coverage fit into these health plans?

Let’s begin with testing. The Families First Coronavirus Response Act states the Medicare, Medicaid, and private health insurance plans are required to cover the cost of Coronavirus testing, without cost-sharing or pre-authorization requirements. This is including lab service costs and provider fees at doctor’s offices, urgent care clinics, and emergency rooms where tests are given. Because this act is federal law, self-insured and fully-insured plans apply to this rule. However, the testing coverage requirements that are imposed on some states are only applicable to fully-insured plans.

Plans that are not considered minimum essential coverage, for example short-term health plans, fixed indemnity plans, and healthcare sharing ministry plans, are not required to cover COVID-19 testing. Some of these plans do volunteer to cover COVID-19 testing, so look to your plan for specifics.

Some states, like Washington, have extended their testing coverage requirements to include these short-term plans, but most states have not imposed further requirements for these plans.

If you are uninsured, states can use their Medicaid programs to cover COVID-19 testing to cover their uninsured residents. There is $1 billion in federal funding to reimburse providers to cover COVID-19 testing for uninsured patients.

Now, let’s get into treatment coverage. As of right now, there is no specific treatment for COVID-19, most people will not need treatment, but around 20% of patients will be hospitalized, and 20% of those patients will need intensive care. This inpatient care is considered an essential health benefit for all ACA-compliant individual and small group health plans. Large group plans are technically not required to cover essential health benefits, but they are required to provide “substantial” coverage for inpatient care.

Even with coverage, inpatient care is expensive. The ACA states that all non-grandfathered/grandmothered plans must have in-network out-of-pocket maximums that can reach up to $8,150 for a single individual. Most COVID-19 treatment costs will not exceed this amount, but many health plans out-of-pocket limits are below that amount. Which leaves patients that need hospitalization with a four-figure invoice.

Some states, like New Mexico and Massachusetts have required state-regulated insurers to cover treatment and testing without cost-sharing. Minnesota is encouraging their providers to do the same. 

Most states are both encouraging and requiring state-regulated providers to allow testing and treatment as in-network, whether or not the medical providers are in the plan’s network. Patients may still be subject to balance billing because out-of-network providers do not need to accept the payment as payment-in-full.

Here are some ways to ensure that you are protected during these uncertain times:

  • If you are uninsured there is a COVID-19 special enrollment period in some states. If your state is included, an ACA-compliant plan is a great option. If you have a low income, you could also be eligible for Medicaid.
  • If you currently have health insurance, understand what your plan covers, and how your cost-sharing responsibilities for in-patient and out-patient care may apply.
  • Look at your health plan to see how it handles prior authorizations.
  • Look at the details of your health plan’s provider network. If you see in-network providers you have a better chance of avoiding balance billing.
  • Check to see if telehealth is covered, for less-severe cases, this is the best way to help prevent the spread of COVID-19. Some health plans are eliminating or reducing cost-sharing for telehealth services.
  • If you have an HSA-qualified plan, you can devote your pre-tax money to your account for the year. The money you contribute to your plan is able to be withdrawn tax-free for out-of-pocket health care expenses.

What Employers Need to Know About FFRCA and Benefits

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The Coronavirus pandemic has had a massive impact on the financial health of thousands of companies in the United States. These employers have seen the enormous reduction in business and the effect it has on their employee benefit programs, and adjust them to meet the needs of both their employees and their business. These adjustments still carry certain obligations the employer must meet under federal legislation. So what do employers need to know about FFRCA and benefits?

Employers have had to reduce or terminate a portion of their workforce, put furloughs in place, and reduce hours and compensation for their employees in response to the crisis. All of these changes impact the employee’s benefit plans and policies, so an employer must review said plans and policies and make adjustments accordingly. Here’s what to consider while doing so:

Service provider contracts for employee benefit plans

Review the terms for existing contracts with multiple service providers, as the fees related to administrative contracts can be determined by the number of participants on your plan. Any reduction in workforce or hours for your employees would affect the total number of eligible employees, which could result in additional fees within the contract. The stay-at-home order may affect a service providers ability to meet their obligations within the contract, as well. Many of these contracts will contain a “Force Majeure” clause that excuses a party for nonperformance due to extraordinary events. Each of these provisions is contract-specific — be sure to review yours. A service provider’s nonperformance in regard to ERISA plans could pose a problem for employers. Employers should seek legal advice in terms of navigating their service providers contracts during this unprecedented time.

Emergency Paid Sick Leave and FMLA Expansion

On March 18, 2020, The Families First Coronavirus Relief Act was enacted. It requires employers with fewer than 500 employees to provide paid sick leave and additional FMLA benefits to their employees. Because of the added cost to employers, the FFRCA provides a quarterly payroll tax credit which is equivalent to 100% of qualified sick and leave wages paid to employees as emergency paid sick leave and emergency family and medical leave.

Health and Welfare Plans

  • COVID-19 Specific Coverage: The FFCRA requires group health plans to cover COVID-19 diagnostic testing related costs, healthcare provider services, and facility costs without the participant’s deductibles, copay, or coinsurance. The FFCRA also ensures that prior authorization and other medical management requirements be waived regarding COVID-19 services. In addition to the FFCRA, the CARES Act requires group health plans to cover preventive services and vaccines related to COVID-19.
  • Reduction in hours (or furloughing): Specific plan or policy terms determine whether furloughed employees or employees with a reduction of hours can keep their health coverage. Many plans require employees to uphold a minimum amount of hours to maintain coverage. Employers might be able to amend their plan or alter the policy to expand coverage or modify procedures for employee premium payments, but must seek approval from their insurance provider before any changes take place. 
  • COBRA Continuation Coverage: COBRA continuation coverage is offered to employees who have been terminated or have reduced hours. Employers can provide a subsidy to help their employees cover the COBRA continuation costs. Be sure to consider any discrimination issues that may arise if the subsidy is not offered throughout your company. 
  • ACA Employer Mandate: ACA requires employers with 50 or more full-time employees (who average 30 hours a week or more) provide minimum essential coverage to their employees.
  • HIPAA: employers who are covered under HIPAA and their associates must remember that HIPAA applies during the COVID-19 pandemic. With changing work conditions, ensure that you review and update HIPAA privacy practices to ensure your safeguards are in place.
  • Cafeteria Plan Elections: There cannot be any change in mid-year election choices based on employment status change. 
  • Premium adjustments: The potential reduction or change in your workforce could affect the employee eligibility for health insurance policies, which could bring about premium adjustments. 
  • Value of welfare benefits: Welfare benefits and their value is tied to employee compensation, reducing their compensation can reduce the value of these benefits for those employees. 

Retirement Plans

  • There are fiduciary responsibilities under ERISA in a market similar to the one COVID-19 has caused. ERISA plans should pay specific attention to fiduciary duties, like acting prudently, diversifying plan assets, and complying with plan provisions. 
  • Participant Access to Retirement Plan Accounts: 
    • The CARES Act permits multiple situations for employees. Employers can expand participant access to specific retirement accounts for “coronavirus-related distribution,” without subjection to 10% early withdrawal penalties and must be repaid over a 3-year period. 
    • The CARES Act also allows employers to increase the maximum loan amount for qualifying individuals if their 401k plan allows participant loans. 
    • Hardship Withdrawals: Most plans allow for hardship withdrawals in areas that are federally declared disaster areas. These withdrawals are still subject to the 10% withdrawal penalty who have not reached the age of 59 ½ and are taxable in the year they are withdrawn. 
    • In-Service Distributions: If the employee has reached the age of 59 ½, many plans allow their participants to receive in-service distributions without a withdrawal penalty. In light of the crisis, employers should consider a plan amendment to expand or add in-service distribution to defined contribution plans or benefit plans.
  • Reducing or Freezing Benefits and Contributions: Employers may be looking to reduce operating costs by reducing or freezing benefits or suspend employer matching or nonelective contributions. This requires at least a 45-day notice before the reduction is put into effect. Discretionary employer matching and nonelective contributions may be suspended or reduced prospectively and may or may not require a plan amendment. Consider the IRS rules that prevent cutbacks in benefits.
  • Funding Relief for Single-Employer Defined Benefit Plans: The CARES Act gives single-employer benefit plans more time to meet funding obligations by delaying the due date until January 1, 2021, with interest on the delayed payment. CARES Act also allows a single-employer defined benefit plan sponsor can elect to treat the plan’s different funding target attainment percentage to the last plan ending before January 1, 2020.
  • Voluntary Termination of Qualified Retirement Plans: Due to the change in economic circumstances some employers may feel they need to terminate their qualified plans. All participants must be fully vested in their accounts under the plan during termination. However, there is a rule that employers who terminate a 401k plan may not establish a new plan within 12 months of the termination. Participants and beneficiaries must receive a special notice at least 45 days prior to the effective date of termination.
  • Partial Termination of Qualified Retirement Plans: Reducing your workforce by 20% or more of qualified retirement plan participants in a plan year that is not considered routine turnover could end up in partial termination of the plan. All participants who have been affected must be fully vested in their accounts. 
  • Deadlines for 403(b) Plans and Pre-Approved Defined Benefit Plans Extended: The IRS is extending the last day of the initial remedial amendment period for 403(b) plans from March 31, 2020, to June 30, 2020. They also are extending both the April 30, 2020 deadlines for an employer to adopt a pre-approved defined benefit plan and submit a determination letter application under the second 6-year remedial amendment cycle and the April 30, 2020 end of the second 6-year remedial amendment cycle for pre-approved defined benefit plans deadline until July 31, 2020.

Incentive Compensation/ Non-Qualified Deferred Compensation Plans

There are strict rules that Code Section 409A adheres to regarding the time and type of payment incentive compensation and other non-qualified deferred compensation a company puts in place. This could include penalties for both the employer and the employees. As you work to navigate potential liquidity issues through the COVID-19, ensure that you navigate Code Section 409 A properly by addressing these issues:

  • Paying Annual Bonuses by March 15th: If you missed the March 15th deadline due to COVID-19 related issues with administrative duties or if the payment jeopardized the employer’s ability to continue, the payment may be made as soon as possible after the unforeseen circumstances are alleviated.
  • Cancellation of Deferrals/ Unscheduled Distributions: In the event of an unforeseeable event, an employee’s deferral election may be canceled, if the plan allows. Employers can also allow a participant to receive distributions if their plan contains these distributions. The employee still must show that emergency expenses cannot be covered by insurance, liquidation of assets, or ceasing deferrals under their plan. The distribution will also be limited to the amount needed to satisfy the participant’s financial needs. 
  • Scheduled Distributions/Distributions Payable Upon Separation From Service: Most non-qualified deferred compensation plans provide payment upon an employee’s separation from service. Separation of service includes termination or a reduction in hours, and the employee would be entitled to a distribution from their plan.
  • Equity Award Considerations: Employers should consider if they should update their stock option valuation that considers the COVID-19 pandemic. This could affect the issuance of equity compensation.
  • Termination of Non-qualified Deferred Compensation Plans: Section 409A does allow a voluntary plan termination and distribution of benefits under specific circumstances, but these rules do not allow termination in connection with a downturn of employers’ financial status. This would require similar non-qualified deferred compensation arrangements to be terminated, and payments would be delayed 12 months after the plan is terminated. Once this is done, the employer cannot adopt a new non-qualified deferred compensation arrangement of the same type for 3 years.

As an employer, there are many things to consider with the changing economic times. For more information visit our site.

ACA Compliance and Workplace Changes

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In just a few months, the coronavirus has caused the global economy to enter a major downturn that could last for years. While nearly everything in our lives has been affected by the pandemic in some way, group health benefits have endured one of the greatest impacts of any industry. Congress has passed new laws, and employers must consider the effect of the layoffs, furloughs, and other workforce changes in regard to the ACA. 

Employers could face penalties from the ACA if they have laid off or furloughed employees without completing a full termination agreement, if they have required employees to use unpaid time off, or if they’ve simply reduced employee hours and subsequently stopped offering benefits. Under the ACA, full-time employees are typically measured by the look-back method, which means the number of full-time employees for 2020 is based on the 2019 number. 

The employers who have terminated employees according to California state laws are not responsible for offering those individuals coverage. Those who have furloughed or moved employees to unpaid leave are responsible for offering coverage. 

When an employee decides to furlough or move their employees to an unpaid leave status, they must consider a few things. First, to avoid penalties, they must verify all full-time employees are being offered health coverage while they are furloughed or put on leave. If the employer doesn’t offer coverage to at least 95% of their full-time employees, furloughed, or on unpaid leave status, they open themselves up to a $2,570 penalty for all full-time employees, not including the first 30.

Second, employers should consider the implications of COBRA or 100% percent-of-cost offerings to full-time employees. If full-time employees waive the COBRA offer and subsidize their policy in the Marketplace, the large employee is subject to a penalty of $3,860 per employee that it applies to.

Lastly, employers must document their coverage offerings and ensure that their offerings are made to ensure carrier eligibility considerations are met by contacting their insurance carrier. 

For more information on ACA complaint insurance programs, contact us!

Unemployment and COVID-19

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What You Need to Know About Unemployment and COVID-19

Unemployment numbers have hit a record high over the last few weeks. The global pandemic has caused many people to lose their job, as businesses were forced to close. Losing a job typically brings a loss of benefits. What do you need to know about unemployment benefits, and how they have changed due to COVID-19?

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  • Receive unemployment benefits plus $600: The stimulus bill provided those who applied for unemployment an additional $600 for up to four months.
  • Free-lancers, self-employed, and gig employees are now eligible: Unemployment has expanded to protect these employees if COVID-19 has affected their business.
  • Sick pay and family leave might be the first available: Under the FFCRA employees can receive 80 hours of sick leave will full pay if they are unable to work due to COVID-19. They may also receive up to 12 weeks of family leave if they need to stay home with their children.
  • Furloughed employees are also eligible: Those who have been furloughed, but not completely laid off are also eligible to receive benefits. These employees can receive unemployment benefits and keep their company health insurance.
  • The 7-day waiting period and other eligibility requirements may be waived: The Federal government has decided to provide full funding to applicants in the first week. Those who haven’t been laid off, but can’t work due to COVID-19 are eligible to receive unemployment. Those who were scheduled to begin working, but were unable to due to Coronavirus are also eligible for unemployment benefits.
  • There is a shortage of staff due to last years unemployment rates: In one week 3.4 million unemployment insurance claims were filed during the global pandemic, however, there are not enough people to assist with those claims. The staff numbers for this year are based on last year’s unemployment rates, because last years numbers were low, the staffing is low. Even with the influx of claims, they will get to everybody!

During this uncertain time, be sure to utilize the resources you can, while you can. For more information on COVID-19 Resources, visit our site.