With all the confusion related to coronavirus disease 2019 (COVID-19), employees may be wondering how their essential health benefits (EHBs) will cover them.

Essential Health Benefits Coverage and Coronavirus

With all the confusion related to coronavirus disease 2019 (COVID-19), you may be wondering how your essential health benefits (EHBs) will cover you.

What are EHBs?

From the HealthCare.gov website, EHBs are “a set of 10 categories of services health insurance plans must cover under the Affordable Care Act. These include doctors’ services, inpatient and outpatient hospital care, prescription drug coverage, pregnancy and childbirth, mental health services and more.”

Basically, EHBs are categories of coverage that your health insurance plan must include. The specifics of the plan and what it covers will vary depending on the employer. If you’re unsure what your health plan covers, speak with human resources to learn more.

Do my EHBs currently include coverage for the diagnosis and treatment of COVID-19?

Yes. EHBs generally include coverage for the diagnosis and treatment of COVID-19. However, the exact coverage details and cost-sharing amounts for individual services may vary by plan, and some plans may require prior authorization before these services are covered.

Are isolation and quarantine for the diagnosis of COVID-19 covered as EHBs?

All EHB-benchmark plans cover medically necessary hospitalizations. Medically necessary isolation and quarantine required by and under the supervision of a medical provider during a hospital admission are generally covered as EHBs. The cost-sharing and specific coverage limitations associated with these services may vary by plan. For example, some plans may require prior authorization before these services are covered or apply other limitations.

Quarantine outside of a hospital setting (such as at home) is not a medical benefit, nor is it required to be an EHB. However, other medical benefits that occur in the home may be covered as EHBs if they are required by and provided under the supervision of a medical provider (such as home health care or telemedicine), but this may depend on prior authorization or be subject to cost-sharing or other limitations.

When a COVID-19 vaccine is available, will it be covered as an EHB, and will issuers be permitted to require cost sharing?

A COVID-19 vaccine does not currently exist. However, current law and regulations require specific vaccines to be covered as EHBs without cost sharing and before any applicable deductible is met, if the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommends them. Under current regulations, plans are not required to cover a new vaccine until the beginning of the plan year that is 12 months after ACIP issues a recommendation for it. However, plans may voluntarily choose to cover a vaccine for COVID-19, with or without cost sharing, prior to that date.

In addition, as part of a plan’s responsibility to cover prescription drugs as EHBs (as described above to cover ACIP-recommended vaccines), if a plan does not provide coverage of a vaccine (or other prescription drugs) on the plan’s formulary, enrollees may use the plan’s drug exceptions process to request that the vaccine be covered under their plan.

Employee Next Steps

If you would like to learn more about your health plan and what it specifically covers, speak with human resources.

 

FAQ Source: Centers for Medicare & Medicaid Services

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