CMS Explains COVID-19 Testing and Vaccine Cost Sharing and Coverage

Corporate Synergies' Compliance Department experts

COVID-19 Testing & Immunization Must be Offered without Vaccine Cost Sharing | Corporate Synergies

Guidance clarifies insurers’ obligations regarding testing and vaccine cost sharing.

As the COVID-19 vaccine rollout expands and testing remains essential, the Centers for Medicare and Medicaid’s (CMS) recent guidance goes even further to eliminate cost-related roadblocks. The guidance applies to how group health plans must offer COVID-19 diagnostic testing and vaccinations under the FFCRA and CARES Act, including applicable testing and vaccine cost-sharing requirements.

Testing Guidance

The guidance clarifies that private group health plans and issuers generally cannot use medical screening criteria to deny coverage for COVID-19 tests for asymptomatic individuals without exposure. Such testing must be covered without cost-sharing requirements (including deductibles, copays and coinsurance), prior authorization or other medical management requirements imposed by the plan or insurer.

However, this does not apply to testing provided by employers for employment screening, general workplace health and safety or public health surveillance.

Vaccine Guidance

Similarly, plans and issuers must cover all COVID-19 vaccines without cost sharing (and all other vaccines that have received a recommendation from the Advisory Committee on Immunization Practices [ACIP]). Plans and issuers must also cover the vaccine administration fee without cost sharing, regardless of how the administration is billed or number of doses. Qualifying COVID-19 preventive services must be covered without vaccine cost sharing starting no later than 15 business days after an official federal recommendation.

Next Steps

Employers and plan sponsors should check to ensure that all of the group health plans that they sponsor (whether fully insured or self-insured) are offering COVID-19 diagnostic testing without cost sharing and update their summaries of benefits and coverage (SBCs) as appropriate.

For full details, please see the March 2 Compliance Alert on the Compliance Resource Page.


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