Essential Health Benefits and COVID-19 FAQs

CMS released an FAQ related to Essential Benefit Coverage and COVID-19. Essential Health Benefits include 10 categories of services that health plans must cover under the Affordable Care Act. 

1. Do the Essential Health Benefits (EHB) include coverage for COVID-19 diagnosis and treatment?

Yes. EHB generally includes coverage for  COVID-19 diagnosis and treatment. However, the exact coverage details and cost-sharing amounts for individual services may vary by plan. Some plans may require prior authorization. Non-grandfathered plans purchased by individuals and small employers must provide coverage for 10 categories of EHB including qualified health plans purchased on the Exchanges. These 10 categories of benefits include, among other things, hospitalization, and laboratory services.

Under current regulations, each state and the District of Columbia generally determines benefits that plans in that state must cover within the 10 EHB categories. This standard set of benefits determined by the state is called the EHB-benchmark plan. All 51 EHB-benchmark plans provide coverage for  COVID-19 diagnosis and treatment.

Many health plans have publicly announced that COVID-19 diagnostic tests are covered benefits and that they will be waiving any cost-sharing that would otherwise apply to the test. Also, many states are encouraging their issuers to cover a variety of COVID-19 related services without cost-sharing, including testing and treatment. Several states have announced that health plans in the state must cover the diagnostic testing of COVID-19 without cost-sharing and waive any prior authorization requirements for such testing.

2. Is isolation and quarantine for the diagnosis of COVID-19 covered as EHB?

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 EHB. Cost-sharing and specific coverage limitations may vary by plan. For example, some plans may require prior authorization before these services are covered or they may apply other limitations.

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

3. Is the COVID-19 vaccine covered as EHB, and can issuers require cost-sharing?

Under current regulations, if ACIP recommends a new vaccine, plans are not required to cover the vaccine until the beginning of the plan year that is 12 months after ACIP issues the recommendation. However, plans may choose to cover a vaccine for COVID-19, with or without cost-sharing, before that date.

Also, if a plan does not provide coverage of a vaccine (or other prescription drugs) on their formulary, enrollees may use the plan’s drug exceptions process to request that the vaccine be covered under their plan, pursuant to 45 CFR 156.122(c).