Midweek Update

David Ermer–Uncategorized–

This afternoon, the Affordable Care Act regulators issued FAQ 58 guiding health plans, including FEHB plans, on handling the end of the Covid public health emergency (PHE), which will happen on May 11.

Coverage of Covid diagnostic tests after May 11 (Bold items are the government’s, and italicized items are the FEHBlogs:

Section 6001 of the [Families First Coronavirus Relief Act] FFCRA requires plans and issuers to cover COVID-19 diagnostic tests that meet statutory requirements and certain associated items and services without imposing any cost-sharing requirements, prior authorization, or other medical management requirements. However, that requirement is applicable only to diagnostic tests and associated items and services furnished during any portion of the PHE beginning on or after March 18, 2020. Therefore, a plan or issuer is not required under section 6001 of the FFCRA to cover COVID-19 diagnostic tests and associated items or services furnished after the PHE ends.

Any plan or issuer that provides coverage for COVID-19 diagnostic testing furnished after the PHE ends, including over-the-counter (OTC) COVID-19 diagnostic tests purchased after the PHE ends, is not prohibited from imposing cost-sharing requirements, prior authorization, or other medical management requirements for those items and services under section 6001 of the FFCRA. However, plans and issuers are encouraged to continue to provide this coverage, without imposing cost sharing or medical management requirements, after the PHE ends

The Departments do not explain the closing sentence.

Coverage of approved Covid vaccines post-PHE

On May 12, approved Covid vaccines will be subject to the Affordable Care Act’s preventive services mandate. Consequently, they remain fully covered with no cost sharing when delivered in-network. Out-of-network coverage depends on the plan brochure (FEHB) or SPD (ERISA) language.

HSA, HRA, and FSA reimbursement of Covid testing and treatment is unaffected by the end of the PHC

Notice to members

The Departments encourage plans and issuers to notify participants, beneficiaries, and enrollees of key information regarding coverage of COVID-19 diagnosis and treatment, including testing. This includes the date when the plan or issuer will stop coverage if the plan or issuer chooses to no longer cover COVID-19 diagnostic tests or when the plan or issuer will begin to impose cost-sharing requirements, prior authorization, or other medical management requirements on COVID-19 tests, to the extent applicable under the plan or coverage. The Departments also encourage plans and issuers to continue covering benefits for COVID-19 diagnosis and treatment and for telehealth and remote care services after the end of the PHE.

The Departments then provide specific guidance to ERISA plans concerning notice, COBRA, etc. Nevertheless, the FEHBlog suggests that FEHB plans treat this as a requirement in the absence of OPM guidance.

In other top news of relevance to the FEHBP:

  • The Food and Drug Administration gave Narcan nasal spray over-the-counter status. Narcan’s manufacturer expects that OTC Narcan, which can save the lives of people struck down by an opioid overdose, will appear on pharmacy shelves in September, according to the Wall Street Journal.
  • Beckers Hospital News tells us,
    • “UnitedHealthcare, Aetna and Cigna are moving to trim their prior authorization programs, which providers have criticized as burdensome, The Wall Street Journal reported March 29. 
    • “Starting in the third quarter of 2023, UnitedHealthcare will remove several procedures and medical devices from its list of services requiring prior authorization, according to the report. It also said it would eliminate many prior authorization requirements for gold-card doctors and hospitals beginning next year. 
    • “We’re not deaf to the complaints out there,” Philip Kaufman, UnitedHealthcare’s chief growth officer, told the Journal. “We’ve taken a hard look at ourselves and this process.”
    • “The payer processes about 13 million prior authorization requests a year out of about 600 million claims, according to the report. Officials said the changes are projected to reduce the number of prior authorization to about 10 million per year. 
    • “Cigna said it has been removing prior authorization requirements for about 500 services and devices since 2020, according to the report. Aetna said it is working to automate and simplify the prior authorization process. 
    • “American Medical Association President Jack Resneck Jr., MD, told the Journal he is cautiously optimistic about UnitedHealthcare’s changes but wants to see the details to be sure they will bring meaningful improvements.”
  • FedWeek points out the OPM Inspector General issued an evaluation report on telehealth utilization during the pandemic earlier this month.
    • “In a sampling of telehealth claims, auditors found more than 2,000 related to services that “could not be performed via telehealth”—including for laser surgery, anesthesia, injections and colonoscopies—and billing for procedures incompatible with the provider’s specialty.
    • “However, OPM management disagreed with the IG’s recommendations in those areas, for example pointing out that telehealth is a well-established concept. 
    • “The IG in turn disagreed, saying that “While telehealth is not a new offering in the FEHB, the variety of services offered and the technologies utilized have increased. When combined with the overall increase in telehealth utilization, we believe increased scrutiny and increased protections are both warranted moving forward.”

In U.S.healthcare business news, Healthcare Dive informs us

CVS closed its $8 billion acquisition of Signify on Wednesday. In a statement, CVS CEO Karen Lynch said the transaction will advance the company’s value-based care strategy by enhancing its presence in the home.

CVS and Signify will work on care delivery and engagement particularly for Medicare Advantage customers, according to a release on the deal’s close.

In conference news, Fierce Healthcare continues to report from the ViVE 2023 healthcare tech conference here and here. The FEHBlog will summarize his thoughts on the OPM carrier conference in Thursday’s post.