COVID-19 and Private Health Insurance Coverage: Frequently Asked Questions

COVID-19 and Private Health Insurance
August 24, 2020
Coverage: Frequently Asked Questions
Vanessa C. Forsberg
The United States is reporting some of the highest numbers of cases and deaths from the
Analyst in Health Care
Coronavirus Disease 2019 (COVID-19) pandemic globally, and the virus is affecting
Financing
communities nationwide. As private health insurance is the predominant source of health

coverage in the United States, there is considerable congressional interest in understanding
private health insurance coverage of health benefits related to COVID-19. This report addresses

frequently asked questions about private health insurance covered benefits and consumer cost
sharing related to COVID-19 testing, treatment, and a potential vaccine. It explains relevant legislation enacted in 2020,
references existing federal requirements, discusses recent administrative guidance, and notes state and private-sector actions.
Federal and state health insurance requirements may relate to covered benefits and consumer cost sharing, among many other
topics. These requirements can vary by coverage type (i.e., individual coverage, fully insured small- and large-group
coverage, and self-insured plans). Covered benefits, consumer costs, and other plan features may vary by plan within each
type of coverage, subject to applicable federal and state requirements.
The following bullets summarize federal requirements related to coverage and cost sharing (which includes deductibles,
coinsurance, and copayments) of COVID-19 testing, treatment, and vaccination. Additional details are addressed in the
report, including the applicability of the requirements to different types of plans; whether the coverage requirements apply
even when furnished by out-of-network providers; whether plans are allowed to impose prior authorization or other medical
management techniques; and the applicable dates of any coverage requirements.
COVID-19 Testing. The Families First Coronavirus Response Act (FFCRA; P.L. 116-127), as amended by
the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136), requires most private
health insurance plans to cover COVID-19 testing, administration of the test, and related items and
services, as defined by the acts. This coverage must be provided without consumer cost sharing.
COVID-19 Treatment. There are no federal requirements that specifically require coverage of COVID-19
treatment. However, the existing federal requirement that certain plans cover a set of 10 categories of
essential health benefits (EHB) is potentially relevant to coverage of COVID-19 treatment items and
services, depending on state and plan variation with regard to implementation of this requirement. Even
where treatment items and services are required to be covered as EHB, cost sharing could apply.
COVID-19 Vaccine. As of the date of this report, there is no vaccine against COVID-19 approved by the
Food and Drug Administration (FDA) for use in the United States, although several candidates are in
development. The CARES Act requires most plans to cover a COVID-19 vaccine, when available, without
cost sharing, if it is recommended by the Advisory Committee on Immunization Practices (ACIP).
Similarly, most plans must cover, without cost sharing, any other COVID-19 preventive services that are
recommended for use by the United States Preventive Services Task Force (USPSTF).
Some states have also announced relevant requirements on the plans they regulate, and some insurers have reported that they
will cover certain relevant benefits. Several organizations are tracking these announcements, as noted in this report.
Congressional Research Service (CRS) experts on other topics related to private health insurance and COVID-19, including
types of plans and coverage of benefits not addressed in this report, are listed in the Appendix for the benefit of
congressional clients. For information on other COVID-19 issues, congressional clients can access the CRS Coronavirus
Disease resources page at https://www.crs.gov/resources/coronavirus-disease-2019.
Congressional Research Service


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Contents
Introduction ................................................................................................................... 1
Background on Private Health Insurance ............................................................................ 2
FAQ: COVID-19 Covered Benefits and Cost Sharing ........................................................... 3
Are Plans Required to Cover COVID-19 Testing? .......................................................... 6
FFCRA and CARES Act........................................................................................ 6
State and Private-Sector Actions ............................................................................. 9
Are Plans Required to Cover COVID-19 Treatment?....................................................... 9
Essential Health Benefits Guidance on COVID-19 Coverage ...................................... 9
Certain Federal Requirements Related to Cost Sharing ............................................. 11
State and Private-Sector Actions ........................................................................... 11

Will Plans Be Required to Cover a COVID-19 Vaccine? ................................................ 12
CARES Act and Existing Preventive Services Coverage Requirements....................... 12
State and Private-Sector Actions ........................................................................... 13

Tables
Table 1. Applicability of Federal COVID-19 Coverage Requirements to
Private Health Insurance Plans ....................................................................................... 4

Table A-1. Resources for Further Questions About Private Health Insurance .......................... 15

Appendixes
Appendix. Resources for Questions about Private Health Insurance and COVID-19 ................ 14

Contacts
Author Information ....................................................................................................... 17


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Introduction
The United States is reporting some of the highest numbers of cases and deaths from the
Coronavirus Disease 2019 (COVID-19) pandemic global y, and the virus is affecting
communities nationwide. As private health insurance is the predominant source of health
coverage in the United States,1 there is considerable congressional interest in understanding
private health insurance coverage of health benefits related to COVID-19 diagnosis, treatment,
and prevention.
This report addresses frequently asked questions about covered benefits and consumer cost
sharing related to COVID-19 testing, treatment, and a potential vaccine. It explains relevant
legislation enacted in 2020, references existing federal requirements, discusses recent
administrative guidance, and notes state and private-sector actions. It begins with background
information on types and regulation of private health insurance plans.
The Families First Coronavirus Response Act (FFCRA; P.L. 116-127)2 requires specified types of
private health insurance plans to cover COVID-19 testing, administration of the test, and related
items and services, without consumer cost sharing. The Coronavirus Aid, Relief, and Economic
Security Act (CARES Act; P.L. 116-136)3 further addresses private health insurance coverage of
COVID-19 testing, and requires coverage of a potential vaccine and other preventive services
without cost sharing, if they are recommended by specified federal entities. There are no federal
requirements that specifical y require coverage of COVID-19 treatment services. However, one or
more existing federal requirements are potential y relevant, as discussed in this report. Some
states have also announced requirements related to covered benefits and consumer costs, and
some insurers have reported that they wil voluntarily cover certain relevant benefits.
This report discusses most U.S. private health insurance plans’ coverage of health care items and
services related to COVID-19, but it general y does not discuss the delivery of those services,
insurers’ payments to health care providers, or private health insurance coverage of other benefits.
The Appendix lists Congressional Research Service (CRS) analysts who can discuss with
congressional clients other topics of interest related to private health insurance and COVID-19,
including types of plans and coverage of benefits not addressed in this report. Also beyond the
scope of this report are public health coverage programs (e.g., Medicare); the domestic and
international public health responses to COVID-19; and economic, human services, and other
nonhealth issues. For further information on these topics, congressional clients can access the
CRS Coronavirus Disease 2019 resources page at https://www.crs.gov/resources/coronavirus-
disease-2019.
The information in this report is current as of its publication date and may be superseded by
subsequent congressional or administrative action. Congressional clients may contact the report
author and/or the experts listed in the Appendix for questions about further developments. In

1 For more information and coverage estimates, see CRS In Focus IF10830, U.S. Health Care Coverage and Spending.
2 H.R. 6201 was signed into law as the Families First Coronavirus Response Act (FFCRA; P.L. 116-127) on March 18,
2020. See CRS Report R46316, Health Care Provisions in the Fam ilies First Coronavirus Response Act, P.L. 116 -127,
for more information about the health provisions in the act.
3 H.R. 748 was signed into law as the Coronavirus Aid, Relief, and Economic Security Act (CARES Act; P.L. 116-136)
on March 27, 2020. See CRS Report R46334, Selected Health Provisions in Title III of the CARES Act (P.L. 116 -136)
for more information about the health provisions in the act.
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addition, Centers for Medicare & Medicaid Services (CMS) guidance related to private health
insurance and COVID-19 is compiled on its website.4
Background on Private Health Insurance
The private health insurance market includes both the group market (largely made up of
employer-sponsored insurance) and the individual market (which includes plans directly
purchased from an insurer). The group market is divided into smal - and large-group market
segments; a small group is typical y defined as a group of up to 50 individuals (e.g., employees),
and a large group is typical y defined as one with 51 or more individuals.5 Employers and other
group health plan sponsors may purchase coverage from an insurer in the smal - and large-group
markets (i.e., they may fully insure). Sponsors may instead finance coverage themselves (i.e., they
may self-insure).6 The individual and smal -group markets include plans sold on and off the
individual and smal -group health insurance exchanges, respectively.7
Covered benefits, consumer costs, and other plan features may vary by plan, subject to applicable
federal and state requirements. The federal government may regulate al the coverage types noted
above (i.e., individual coverage, fully insured smal - and large-group coverage, and self-insured
group plans), and states may regulate al but self-insured group plans. Federal and state
requirements may vary by coverage type.8
This report focuses on private-sector plans explained above.9 There are some variations of these
coverage types, and there are other types of private health coverage arrangements, which may or
may not be subject to the requirements discussed in this report, or for which there may be other
policy questions related to COVID-19. These other coverage types are out of the scope of this
report, but a number of them are identified in the Appendix, along with resources for further
information.
One coverage variation, grandfathered plans, is included in this report because it is explicitly
referenced in legislation relevant to COVID-19 and private health insurance coverage.
Grandfathered plans are individual or group plans in which at least one individual was enrolled as
of enactment of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148, as amended),

4 See Centers for Medicare & Medicaid Services (CMS), T he Center for Consumer Information and Insurance
Oversight (CCIIO), “ Coronavirus Disease 2019 (COVID-19) Guidance,” accessed April 28, 2020, at
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs#COVID-19.
5 In general, for purposes of health insurance requirements, small groups are those with 50 or fewer individuals (e.g.,
employees). States can also define them as having 100 or fewer individuals. T he definition of large group is 51 or more
individuals, or 101 or more individuals, depending on the definition of small group.
6 Employers and other plan sponsors may purchase coverage from state-licensed insurers and offer it to their employees
or other group members. Employers and other plan sponsors that obtain h ealth insurance plans in this way are referred
to as being fully insured. Employers or other plan sponsors that self-insure set aside funds to pay for health benefits
directly, and they bear the risk of covering medical expenses generated by the individuals covered under the self -
insured plan.
7 T he health insurance exchanges are virtual marketplaces in which consumers and small businesses can shop for and
purchase private health insurance coverage. For more information, see CRS Report R44065, Overview of Health
Insurance Exchanges
.
8 For more information about types of plans and regulation of them, see CRS Report R45146, Federal Requirements on
Private Health Insurance Plans
.
9 In terms of group coverage, this report focuses on group plans sponsored by private-sector employers and other
sponsors. Some information in this report may also apply to federal, state, and local government employee group plans.
See the Appe ndix for resources on federal employee and other types of government plans.
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and which continue to meet certain criteria.10 Plans that maintain their grandfathered status are
exempt from some, but not al , federal requirements.
Another type of coverage, short-term, limited duration insurance (STLDI or STLD plans), is also
included in this report, because it is explicitly excluded from a coverage definition cited by
relevant legislation. STLDI is coverage, general y sold in the individual market, which meets
certain definitional criteria. The statutory definition of “individual health insurance coverage”
excludes STLDI; thus, STLDI is exempt from complying with al federal health insurance
requirements applicable to individual health insurance plans.11
FAQ: COVID-19 Covered Benefits and Cost Sharing
The remainder of this report addresses private health insurance coverage of COVID-19 testing,
treatment, and vaccination, when a vaccine becomes available. Where there are federal
requirements related to such coverage, it is useful to understand the following:
 Is the service or item required to be covered? If so, is cost sharing al owed? In
general, private health insurance cost sharing includes deductibles, coinsurance,
and copayments.12
 Are plans al owed to impose prior authorization or other medical management
requirements? For example, some insurers require that they (the insurer) provide
prior authorization for routine hospital inpatient care, and/or require that primary
care physicians provide approval or referrals for specialty care, as a condition for
covering the care.13
 Does the coverage requirement depend on how or where the service or item is
furnished (e.g., by an in-network versus out-of-network provider)? Under private
insurance, benefit coverage and consumer cost sharing is often contingent upon
whether the service or item is furnished by a provider that the insurer has
contracted with (i.e., whether that provider is in network for a given plan). In
instances where a contract between an insurer and provider does not exist, the
provider is considered out of network.14
 When is the coverage requirement in effect?
 What types of plans are subject to the coverage requirement?
To the extent that information is available, these issues are addressed with regard to private health
insurance coverage of COVID-19 testing, treatment, and vaccination. Table 1 summarizes key
information.


10 T he ACA was enacted on March 23, 2010. For more information about grandfathered plans, see CRS Report
R46003, Applicability of Federal Requirem ents to Selected Health Coverage Arrangem ents.
11 See 42 U.S.C. §300gg-91(b)(5). For more information about ST LDI, see the report cited in footnote 10.
12 A deductible is the amount an insured consumer pays for covered health care services before coverage begins (with
exceptions). Coinsurance is the share of costs, figured in percentage form, an insured consumer pays for a covered
health service. A copaym ent is the fixed dollar amount an insured consumer pays for a covered health service.
13 For more information, see the appendix of CRS Report RL32237, Health Insurance: A Primer.
14 For more information, see the background section of CRS Report R46116, Surprise Billing in Private Health
Insurance: Overview and Federal Policy Considerations
.
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Table 1. Applicability of Federal COVID-19 Coverage Requirements to Private Health Insurance Plans
Group Marketc
Medical
Also
Management
Applies
Fully Insurede
Coverage and Cost-Sharing
Approaches
Out-of-
Large
Small
Self-
Individual
Authority
Requirements
Allowed?a
Network?b
Time Frame
Groupg
Groupg
Insuredf
Marketd
Testing
COVID-19 testing, administration of the
FFCRA enactment
FFCRA §6001
test, and related items and services, as
(March 18, 2020)
(as amended by
defined, must be covered without cost
Prohibited
Yes
through declared
√ (+GF)i
√ (+GF)i
√ (+GF)i
√ (+GF)i
CARES Act §3201)
sharing.
COVID-19 PHE.h
Treatment
42 U.S.C. §18022;
EHB requirements may apply to coverage of
Permanent; existed
CMS March 5, 2020,
COVID-19 treatment services, subject to
Al owed; may
No
prior to COVID-19
N.A.

N.A.

and March 12, 2020,
state and plan variation. Cost sharing is
vary by plan
pandemic.
guidancej
possible and may vary by plan.
Where EHB requirements are applicable,
Permanent; existed
42 U.S.C. §18022
certain other requirements are also
N.A.
No
prior to COVID-19
√k

√k

applicable, such as the limit on annual out-
pandemic.
of-pocket spending on EHB benefits.
Vaccination
COVID-19 vaccination items and services
must be covered without cost sharing if
15 business days after
recommended by ACIP. Other COVID-19
Al owed; may
ACIP or USPSTF
CARES Act §3203
preventive items and services must be
vary by plan
No
recommendation; not




covered without cost sharing if
limited to declared
recommended by the USPSTF.l
COVID-19 PHE.
Source: CRS analysis of relevant legislation, statute, regulation, and guidance.
Notes: Checkmark (√) indicates that the requirement is applicable to that type of health plan. The variation (+GF) indicates that the requirement is also applicable to
grandfathered plans; see table note (i). N.A. indicates that the requirement is not applicable to that type of health plan. None of these requirements applies to short-term,
limited duration insurance (STLDI); see table note (d). “FFCRA” is the Families First Coronavirus Response Act (P.L. 116-127). “CARES Act” is the Coronavirus Aid,
Relief, and Economic Security Act (P.L. 116-136). “PHE” is the public health emergency for COVID-19 declared pursuant to Section 319 of the Public Health Service Act;
see table note (h). “USPSTF” is the United States Preventive Services Task Force. “EHB” is essential health benefits. “ACIP” is the Advisory Council on Immunization
Practices.
CRS-4


The requirements listed in the table do not comprise a comprehensive list of al federal requirements and standards that apply to al health plans.
a. An example of a medical management technique that insurers may use, as al owed, is requiring that they (the insurer) provide prior authorization for coverage of
certain services. For more information, see the appendix of CRS Report RL32237, Health Insurance: A Primer.
b. Al requirements apply to services or items furnished in network. Under private insurance, benefit coverage and consumer cost sharing are often contingent upon
whether a service or item is furnished by a provider that the insurer has contracted with (i.e., whether that provider is in network for a given plan). In instances
where a contract between an insurer and provider does not exist, the provider is considered out of network. For more information, see the background section of
CRS Report R46116, Surprise Bil ing in Private Health Insurance: Overview and Federal Policy Considerations.
c. Health insurance may be provided to a group of people who are drawn together by an employer or other organization, such as a trade union. Such groups general y
are formed for purposes other than obtaining insurance, such as employment. When insurance is provided to a group, it is referred to as group coverage or group
insurance. In the group market, the entity that purchases health insurance on behalf of a group is referred to as the plan sponsor.
d. Consumers who are not associated with a group can obtain health coverage by purchasing it directly from an insurer in the ind ividual (or nongroup) health
insurance market. Although STLDI is a type of coverage general y sold in the individual market, the statutory definition of individual health insurance coverage
excludes STLDI. Thus, no federal health insurance requirements on individual health insurance plans apply to STLDI.
e. A ful y insured health plan is one in which the plan sponsor purchases health coverage from a state-licensed insurer; the insurer assumes the risk of paying the
medical claims for benefits covered under the health plan of the sponsor’s enrol ed members.
f.
Self-insured plans refer to health coverage that is provided directly by the organization sponsoring coverage for its members (e.g., a firm providing health benefits to
its employees). Such organizations set aside funds and pay for health benefits directly. Under self-insurance, the organization bears the risk for covering medical
claims. In general, the size of a self-insured employer does not affect the applicability of federal requirements.
g. In general, for purposes of health insurance requirements, smal groups are those with 50 or fewer individuals (e.g., employees). States can also define them as having
100 or fewer individuals. The definition of large group is 51 or more individuals, or 101 or more individuals, depending on t he definition of smal group.
h. Some coverage requirements in FFCRA and the CARES Act refer to the “emergency period” or a similar construction. This refers to the public health emergency
declared with respect to the COVID-19 outbreak by Secretary of Health and Human Services (HHS) Alex Azar on January 31, 2020, effective as of January 27,
pursuant to Section 319 of the Public Health Service Act. Hence, the emergency period began on January 27, 2020, and remains in effect as long as the declaration,
or any renewal of it, is in effect. See “Duration of Emergency Period” in CRS Report R46316, Health Care Provisions in the Families First Coronavirus Response Act, P.L.
116-127
.
i.
Grandfathered plans are individual or group plans in which at least one individual was enrol ed as of enactment of the Patient Protection and Affordable Care Act
(ACA; P.L. 111-148, as amended), and which continue to meet certain criteria. Plans that maintain their grandfathered status are exempt from some federal
requirements. However, FFCRA specifies that its COVID-19 testing coverage requirements do apply to grandfathered plans.
j.
Centers for Medicare & Medicaid Services (CMS), “FAQs on Essential Health Benefit Coverage and the Coronavirus (COVID-19),” March 12, 2020.
CMS, “Information Related to COVID–19 Individual and Smal Group Market Insurance Coverage,” March 5, 2020.
k. Certain types of plans—self-insured plans and plans offered in the large-group market—must comply with this requirement even though they are not required to
cover the EHB. HHS has indicated that such plans must use a permissible definition of EHB (including any state-selected EHB benchmark plans) to determine
whether they comply with the requirement.
l.
Cost sharing for office visits associated with applicable vaccinations and other preventive services may or may not be al owed. In general, this depends on whether
the preventive service or item was the primary purpose of the visit, and whether the service or item was bil ed or tracked separately from the office visit. See 45
C.F.R. §147.130(a)(2).
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FAQ: COVID-19 and Private Health Insurance Coverage

Are Plans Required to Cover COVID-19 Testing?
FFCRA and CARES Act
Prior to the enactment of the FFCRA, there were no federal requirements specifical y mandating
private health insurance coverage of items or services related to COVID-19 testing.
Section 6001 of the FFCRA, as amended, requires most private health insurance plans to cover
COVID-19 testing, administration of the test, and related items and services, as defined in the act.
The coverage must be provided without consumer cost sharing, including deductibles,
copayments, or coinsurance. Prior authorization or other medical management requirements are
prohibited.15 The Department of Labor (DOL), Department of Health and Human Services
(HHS), and Treasury issued FAQ documents on April 11, 2020,16 and June 23, 2020,17 (hereinafter
“Tri-Agency April 11 FAQ” and “Tri-Agency June 23 FAQ,” respectively) on the private health
insurance coverage requirements in FFCRA and the CARES Act.18
Types of Tests, Related Items and Services, and Testing Settings
FFCRA Section 6001(a)(1), as amended by the CARES Act Section 3201, describes the types of
tests that must be covered, along with the administration of such tests. Together, the acts require
coverage of in-vitro diagnostic tests (as defined in Food and Drug Administration [FDA]
regulation)19 that detect SARS-CoV-2 or diagnose the virus that causes COVID-19 and are
approved, cleared, or authorized for marketing by the agency or being marketed or clinical y used
pursuant to an al owed flexibility in FDA guidance. The acts did not explicitly state whether this
included serology testing.20 The Tri-Agency April 11 FAQ interpreted the coverage requirement
as applying to diagnostic (i.e., molecular and antigen) and serological (i.e., antibody) tests.
Together, the acts, as interpreted by the agencies through guidance, also require coverage without
cost sharing of
items and services furnished to an individual during [specified types of visits; discussed
below] that result in an order for or administration of [an applicable COVID-19 test; see
above], but only to the extent such items and services relate to the furnishing or

15 See the introduction to this section regarding cost sharing and prior authorization requirements.
16 Department of Labor (DOL), HHS, and T reasury, “ FAQS ABOUT FAMILIES FIRST CORONAVIRUS
RESPONSE ACT AND CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURIT Y ACT IMPLEMENT AT ION
PART 42,” April 11, 2020, at https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf. Hereinafter referred to
as T ri-Agency April 11 FAQ.
17 DOL, HHS, and T reasury, “FAQS ABOUT FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND
CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURIT Y ACT IMPLEMENT ATION PART 43,” June 23,
2020, at https://www.cms.gov/files/document/FFCRA-Part -43-FAQs.pdf. Hereinafter referred to as T ri-Agency June
23 FAQ.
18 For a discussion of the agencies’ implementation authority and the fo rce of law of these documents, see “Are Plans
Required to Cover T esting for Public Health Surveillance or Employment Purposes?” in CRS Report R46481, COVID-
19 Testing: Frequently Asked Questions
.
19 21 C.F.R. §809.3(a).
20 Although both serology tests and molecular and antigen diagnostic tests meet the regulatory definition of “in vitro
diagnostic,” applicability to serology testing was not clear based only on the statutory language as it refers to detection
and identification of the virus. Serology testing does not detect or identify the virus; rather, it detects antibodies. For
more information, see “What Are the Different T ypes of COVID-19 T ests?” in CRS Report R46481, COVID-19
Testing: Frequently Asked Questions
.
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administration of such product or to the evaluation of such individual for purposes of
determining the need of such individual for such product.21
Per an example provided in guidance,
if the individual’s attending provider determines that other tests (e.g., influenza tests, blood
tests, etc.) should be performed during a visit … to determine the need of such individual
for COVID-19 diagnostic testing, and the visit results in an order for, or administratio n of,
COVID-19 diagnostic testing, the plan or issuer must provide coverage for the related tests
under section 6001(a) of the FFCRA.22
In addition, consumers must not face cost-sharing for “facility fees” or other fees, to the extent
they are related to COVID-19 testing or related items and services that are required to be covered
under FFCRA Section 6001.23
The coverage requirements do not apply to any services or items furnished at a testing visit that
are not related to COVID-19 (e.g., if someone received testing or treatment for an unrelated
condition at the same visit). In addition, the law and guidance do not explicitly address coverage
and cost-sharing for the “related” items and services discussed above if the individual does not
ultimately receive the test.24 The requirements also do not encompass treatment for il nesses
associated with COVID-19.25
Per FFCRA Section 6001(a)(2), the coverage requirements apply to the specified items and
services, discussed above, when furnished at visits including to health care provider offices
(including in-person and telehealth visits), urgent care centers, and emergency rooms. Per the Tri-
Agency April 11 FAQ, the requirements also apply at “nontraditional” settings, “including drive-
through screening and testing sites where licensed health care providers are administering
COVID-19 diagnostic testing.”26 Also see “Testing for Public Health Surveil ance or Employment
Purposes” in this report.
In addition, guidance indicates that the coverage requirements apply to at-home COVID-19 tests,
including at-home swab kits that may be sent to a lab for processing, when such tests are “ordered
by an attending health care provider who has determined that the test is medical y appropriate for
the individual,” as specified in guidance.27

21 FFCRA §6001(a)(2). Also see the T ri-Agency April 11 FAQ, including questions five, six, and eight.
22 T ri-Agency April 11 FAQ, question five.
23 For more information, see the T ri-Agency June 23 FAQ, question seven, including its footnote 16.
24 Per the T ri-Agency April 11 FAQ, question five, the coverage of related items and services is required when “the
visit results in an order for, or administration of, COVID-19 diagnostic testing.” T his language also appears in FFCRA
Section 6001(a)(2). T he statute and guidance do not explicitly address whether the coverage requirements apply if an
individual receives the related items and services, even for purposes of determining the need for COVID -19 testing, but
does not actually receive a COVID-19 test. Other federal and/or state requirements could be applicable.
25 See “Are Plans Required to Cover COVID-19 T reatment?” in this report for more information.
26 See T ri-Agency April 11 FAQ, question eight , regarding “nontraditional” visits. Also see question 13 for more
information about telehealth visits.
27 T ri-Agency June 23 FAQ, question four. Also see question three regarding “attending providers.”
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Timing of Requirements and Applicability to Different Types of Plans
The coverage requirements in FFCRA apply only to the specified items and services that are
furnished during the COVID-19 public health emergency period described in that act, as of the
date the FFCRA was enacted (March 18, 2020).28
These requirements apply to individual health insurance coverage and to smal - and large-group
plans, whether fully insured or self-insured.29 This includes grandfathered individual or group
plans, which are exempt from certain other federal private health insurance requirements. Per the
definition of individual health insurance coverage cited in the act, the requirements do not apply
to STLDI.30
Testing for Public Health Surveillance or Employment Purposes
For further discussion of this topic, see “Are Plans Required to Cover Testing for Public Health
Surveil ance or Employment Purposes?” in CRS Report R46481, COVID-19 Testing: Frequently
Asked Questions
. That report also addresses coverage of repeated testing and testing of
asymptomatic individuals.
The Tri-Agency April 11 FAQ interpreted FFCRA Section 6001 as compel ing plans to cover
testing only “when medical y appropriate for the individual, as determined by the individual’s
attending healthcare provider in accordance with accepted standards of current medical
practice.”31 The guidance did not further outline the circumstances in which COVID-19 tests were
“medical y appropriate”; however, under the agencies’ interpretation, the availability of covered
testing appeared contingent upon a medical decision by a health care provider responsible for
providing care to a specific patient.
The Tri-Agency June 23 FAQ addressed coverage of COVID-19 testing for surveil ance or
employment purposes. In this guidance, the agencies specified that testing
conducted to screen for general workplace health and safety (such as employee ‘return-to-
work’ programs), for public health surveillance for SARS-CoV-2, or for any other purpose
not primarily intended for individualized diagnosis or treatment of COVID-19 or another
health condition is beyond the scope of section 6001 of the FFCRA.32
Out-of-Network Testing
FFCRA does not specify whether its coverage requirements apply when the test is furnished by an
out-of-network provider. However, Section 3202 of the CARES Act addresses insurer payments

28 Some coverage requirements in FFCRA and the CARES Act refer to the “emergency period” or similar construction.
T his refers to the public health emergency declared with respect to the COVID-19 outbreak by HHS Secretary Alex
Azar on January 31, 2020, effective as of January 27, pursuant to §319 of the Public Health Service Act (PHSA).
Hence, the emergency period began on January 27, 2020, and remains in effect as long as the declaration, or any
renewal of it, is in effect. See “Duration of Emergency Period” in CRS Report R46316, Health Care Provisions in the
Fam ilies First Coronavirus Response Act, P.L. 116 -127
, for more information.
29 T he requirements are technically applicable to group health plans and health insurers offering individual and group
health insurance coverage. In this report, references to “plans” include applicable plans and insurers.
30 See “Background on Private Health Insurance” regarding these types of plans, including grandfathered plans and
ST LDI.
31 T ri-Agency April 11 FAQ, question six.
32 T ri-Agency June 23 FAQ, question five.
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to in-network and out-of-network providers. In addition, the Tri-Agency April 11 FAQ clarifies
that the FFCRA coverage requirements apply both in network and out of network.33
For further discussion of coverage and provider reimbursement requirements applicable to out-of-
network testing and “balance bil ing” by out-of-network providers, see “What Coverage and
Provider Reimbursement Requirements Apply to Out-of-Network Testing?” and “Are Out-of-
Network Providers Al owed to Balance Bil Patients for COVID-19 Testing and Other Related
Items and Services?” in CRS Report R46481, COVID-19 Testing: Frequently Asked Questions.
State and Private-Sector Actions
Before and since the enactment of FFCRA, some states have announced coverage requirements,
and some insurers have clarified or expanded their policies regarding coverage of COVID-19
testing, among other services.34 However, states cannot regulate self-insured plans, and insurer
announcements do not necessarily apply to those plans. FFCRA does apply to self-insured group
plans in addition to the other plan types discussed above.
To the extent that state requirements about or plans’ voluntary coverage of COVID-19 testing did
not extend as far as FFCRA and CARES Act requirements, the federal laws supersede them.
However, state requirements and plans’ voluntary coverage may exceed applicable federal
requirements, as long as they do not prevent the implementation of any federal requirements.35
A state or local department of health or other administrative agency may announce requirements
or guidelines regarding testing certain populations or testing for certain public health purposes.
However, this does not necessarily mean insurers in that state are required to cover such testing,
although that would be the case if the state department of insurance or other relevant agency also
requires such coverage or if federal requirements are applicable. This is because it is the state
department of insurance, not the state department of health, which regulates insurance.
Even though federal law now requires most plans to cover specified COVID-19 testing services
without cost sharing, it may be useful for consumers to contact their insurers or plan sponsors to
understand their coverage. Subject to applicable federal and state requirements, coverage of the
COVID-19 test and related services and items may vary by plan.
Are Plans Required to Cover COVID-19 Treatment?
Essential Health Benefits Guidance on COVID-19 Coverage
Although FFCRA requires certain plans to cover specified COVID-19 testing services without
cost sharing, neither FFCRA nor the CARES Act mandates coverage of COVID-19 treatment

33 T ri-Agency April 11 FAQ, question seven. Furthermore, question nine of the T ri-Agency June 23 FAQ clarifies that
out-of-network providers are generally precluded from directly billing a patient for the difference between provider’s
charge for COVID-19 testing and the amount reimbursed by the health plan (i.e., balance billing). However, a provider
is not prevented from balance billing for other items and services unless there is an applicable state law or other
prohibition (e.g., pursuant to the terms of the Provider Relief Fund). For background on this funding, see CRS Insight
IN11438, The COVID-19 Health Care Provider Relief Fund.
34 Several organizations are tracking these announcements by states and/or insurers. See, for examp le, the National
Association of Insurance Commissioners (NAIC) at https://content.naic.org/naic_coronavirus_info.htm, and the
Association of Health Insurance Plans (AHIP) at https://www.ahip.org/health-insurance-providers-respond-to-
coronavirus-covid-19/.
35 See, for example, the introduction of the Tri-Agency April 11 FAQ.
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services. There is no federal requirement specifical y mandating private health insurance
coverage of items or services related to COVID-19 treatment. However, one or more existing
federal requirements are potential y relevant, subject to state implementation and plan variation.
There is a federal statutory requirement that certain plans cover a core set of 10 categories of
essential health benefits (EHB).36 However, states, rather than the federal government, general y
specify the benefit coverage requirements within those categories. Current regulation al ows each
state to select an EHB-benchmark plan. The benchmark plan serves as a reference plan on which
plans subject to EHB requirements must substantial y base their benefits packages. Because states
select their own EHB-benchmark plans, there is considerable variation in EHB coverage from
state to state.37
On March 5, 2020, and March 12, 2020, CMS issued guidance addressing the potential relevance
of EHB requirements to coverage of COVID-19 treatment, among other benefits, subject to
variation in states’ EHB-benchmark plan designations.38 According to the March 12 document,
“al 51 EHB-benchmark plans currently provide coverage for the diagnosis and treatment of
COVID-19” (emphasis added), but coverage of specific benefits within the 10 categories of EHB
(e.g., hospitalization, laboratory services) may vary by state and by plan.
The March 12 document suggests that coverage of medical y necessary hospitalizations would
include coverage of medical y necessary isolation and quarantine during the hospital admission,
subject to state and plan variation. Quarantine in other settings, such as at home, is not a medical
benefit. The document notes, “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,” subject to state and plan variation.
The March 12 document confirms that “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.” In other words, even where certain treatment items and services are
required to be covered as EHB in a state, cost-sharing and medical management requirements

36 T he 10 categories of essential health benefits (EHB) are ambulatory patient services; emergency services;
hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral
health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive
and wellness services and chronic disease management; and pediatric services, including oral and vision care.
37 For information about the process for defining the EHB in each state that is in place for plan years beginning before
2020, see CRS Report R44163, The Patient Protection and Affordable Care Act’s Essential Health Benefits (EHB) . On
April 17, 2018, HHS issued a final rule that modifies the process for defining the EHB for plan years beginning in
2020. For more information, see Department of Health and Human Services, “ HHS Notice of Benefit and Payment
Parameters for 2019,” 83 Federal Register 16930, April 17, 2018.
38 Centers for Medicare & Medicaid Services, “FAQs on Essential Health Benefit Coverage and the Coronavirus
(COVID-19),” March 12, 2020, at https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/EHB-
Benchmark-Coverage-of-COVID-19.pdf. T he March 5, 2020, document has similar content: CMS, “ Information
Related to COVID–19 Individual and Small Group Market Insurance Coverage,” at https://www.cms.gov/files/
document/03052020-individual-small-market -covid-19-fact-sheet.pdf. These fact sheets each also addressed policy
considerations related to private health insurance coverage of COVID-19 testing and vaccination. T he enactment of
FFCRA and the CARES Act have likely superseded much of the information in these documents regarding such
coverage of testing and vaccination, but as of the date of this report, the documents are still relevant with regard to
coverage of COVID-19 treatment.
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could apply, subject to applicable federal and state requirements. In addition, cost sharing and
other coverage details may vary for services furnished by out-of-network providers.39
Individual and fully insured smal -group plans are subject to EHB requirements. Large-group
plans, self-insured plans, grandfathered plans, and STLDI are not.40
Whether or not certain treatment services are defined as EHB in a state, other state benefit
coverage requirements may be relevant to COVID-19 treatment. Plans may also voluntarily cover
benefits. See “State and Private-Sector Actions,” below.
Certain Federal Requirements Related to Cost Sharing
Other existing federal requirements are also relevant to consumer cost sharing on COVID-19
treatment services, to the extent that such treatments are covered by the consumer’s plan, and
largely to the extent that they are defined by a state as EHB.
For example, plans must comply with annual limits on consumers’ out-of-pocket spending (i.e.,
cost sharing, including deductibles, coinsurance, and copayments) on in-network coverage of the
EHB.41 If certain treatment services are defined as EHB in a state, and are furnished by an in-
network provider, consumers’ out-of-pocket costs for the plan year would be limited as discussed
below. If certain treatment services are not defined as EHB in a state, and/or are furnished by out-
of-network providers, this out-of-pocket maximum would not necessarily apply.
In 2020, the out-of-pocket limits cannot exceed $8,150 for self-only coverage and $16,300 for
coverage other than self-only. This means that once a consumer has spent up to that amount in
cost sharing on applicable in-network benefits, the plan would cover 100% of remaining
applicable costs for the plan year.
The out-of-pocket maximum applies to individual health insurance coverage and to smal - and
large-group plans, whether fully insured or self-insured.42 The requirement does not apply to
grandfathered plans or STLDI.
State and Private-Sector Actions
As stated above, in recent weeks, some states have announced coverage requirements related to
COVID-19 testing services and items, and some insurers have clarified or expanded their policies
to include relevant coverage.43 Some of these state and insurer statements also address coverage
of treatment services. However, as discussed above, states cannot regulate self-insured plans, and
insurer announcements do not necessarily apply to those plans either.

39 However, see CRS Insight IN11438, The COVID-19 Health Care Provider Relief Fund regarding the prohibition on
Provider Relief Fund recipients from balance billing consumers for “ all care for a presumptive or actual case of
COVID-19.”
40 See “Background on Private Health Insurance” regarding these types of plans, including grandfathered plans and
ST LDI.
41 42 U.S.C. §18022. For more information on this requirement, and on other federal cost -sharing requirements that
may similarly be relevant (prohibition on lifetime limits and annual limits; minimum actuarial value requirements), see
CRS Report R45146, Federal Requirem ents on Private Health Insurance Plans.
42 Certain types of plans—self-insured plans and plans offered in the large-group market—must comply with this
requirement even though they are not required to cover the EHB. HHS has indicated that such plans must use a
permissible definition of EHB (including any state-selected EHB benchmark plans) to determine whether they comply
with the requirement.
43 See footnote 34 regarding organizations that are tracking such activity.
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Coverage, cost sharing, and the application of medical management techniques (e.g., prior
authorization) can vary by plan, subject to applicable federal and state requirements. It may be
useful for consumers to contact their insurers or plan sponsors to understand their coverage of
services and items related to COVID-19 treatment.
Will Plans Be Required to Cover a COVID-19 Vaccine?
CARES Act and Existing Preventive Services Coverage Requirements
As of the date of this report, there is no vaccine against COVID-19 approved by the Food and
Drug Administration (FDA) for use in the United States, although several candidates are in
development. Prior to the enactment of the CARES Act, there were no federal requirements
specifical y mandating private health insurance coverage of items or services related to a COVID-
19 vaccine.
However, per an existing federal requirement (§2713 of the Public Health Service Act [PHSA])
and its accompanying regulations, most plans must cover specified preventive health services
without cost sharing.44 This includes any preventive service recommended with an A or B rating
by the United States Preventive Services Task Force (USPSTF); or any immunization with a
recommendation by the Advisory Committee on Immunization Practices (ACIP), adopted by the
Centers for Disease Control and Prevention (CDC), for routine use for a given individual.45 These
coverage requirements apply no sooner than one year after a new or revised recommendation is
published.46
Requirements of PHSA Section 2713 apply to individual health insurance coverage and to smal -
and large-group plans, whether fully insured or self-insured. The requirements do not apply to
grandfathered plans or to STLDI. By regulation, plans are general y not required to cover
preventive services furnished out of network.47 They are al owed to use “reasonable medical
management” techniques, within provided guidelines. Cost sharing for office visits associated
with a furnished preventive service may or may not be al owed, as specified in regulation.48
Section 3203 of the CARES Act requires specified plans—the same types as those subject to
PHSA Section 2713—to cover a COVID-19 vaccine, when available, and potential y other
COVID-19 preventive services, if they are recommended by ACIP or USPSTF, respectively.49

44 §2713 was added to the PHSA (codified at 42 U.S.C. §300gg-13) and incorporated into the Employee Retirement
Income Security Act (ERISA) and Int ernal Revenue Code (IRC) by the Patient Protection and Affordable Care Act
(ACA; P.L. 111-148, as amended). Regulations are at 45 C.F.R. §147.130; 29 C.F.R. §2590.715-2713; and 26 C.F.R.
§54.9815-2713.
45 For further discussion of this provision, see CRS Report R45146, Federal Requirements on Private Health Insurance
Plans
. For more information about the USPST F and ACIP, see https://uspreventiveservicestaskforce.org/uspstf/ and
https://www.cdc.gov/vaccines/acip/index.html, respectively. For more information about the definition of “ routine”
use, see Richard Hughes IV, Reed Maxim, and Alessandra Fix, “ Vague Vaccine Recommendations May Be Leading
T o Lack Of Provider Clarity, Confusion Over Coverage,” Health Affairs, May 7, 2019.
46 Per 45 C.F.R. §147.130(b), such coverage is required “for plan years (in the individual market, policy years) that
begin on or after the date that is one year after the date the recommendation or guideline is issued.”
47 However, see footnote 39 regarding a provider’s ability to bill the consumer for these services.
48 In general, whether cost sharing for office visits is allowed or prohibited depends on whether the preventive service
or item was the primary purpose of the visit, and whether the service or item was billed or tracked separately from the
office visit. See 45 C.F.R. §147.130(a)(2). Also see 45 C.F.R. §147.130(a)(3) regarding out-of-network coverage and
(a)(4) regarding reasonable medical management.
49 CARES Act §3203 refers to, but does not amend, PHSA §2713.
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This coverage must be provided without cost sharing. Section 3203 also applies an expedited
effective date for the required coverage: 15 business days after an applicable ACIP or USPSTF
recommendation is published. Otherwise, requirements of Section 3203 mirror the existing
requirements under PHSA Section 2713. The requirement to cover COVID-19 vaccination and
other preventive services is not time limited, whereas the FFCRA requirement to cover COVID-
19 testing is limited to the duration of a declared COVID-19 public health emergency. See “Are
Plans Required to Cover COVID-19 Testing?”
State and Private-Sector Actions
Some of the state and insurer announcements about coverage of COVID-19 benefits, discussed
earlier in this report, reference coverage of a potential vaccine.50 However, pending development
and approval of the vaccine, and pending the implementation of the CARES Act requirements
related to COVID-19 vaccine coverage, it is premature to discuss potential variations in coverage
of the vaccine at the state or plan level. It may stil be useful for consumers to contact their
insurers or plan sponsors to understand their coverage of services and items related to a potential
COVID-19 vaccine.

50 See footnote 34.
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Appendix. Resources for Questions about Private
Health Insurance and COVID-19
This report has focused on coverage of COVID-19 testing, treatment, and vaccination by most
types of private health insurance plans. CRS analysts are also available to congressional clients to
discuss other topics of interest related to private health insurance and COVID-19, including
 coverage of COVID-19 benefits by types of private plans not specifical y
addressed in this report;
 other issues related to private coverage of COVID-19 benefits;
 private coverage of certain other benefits of concern during this pandemic, or of
services furnished via telehealth; and
 issues related to private health insurance enrollment and premium payments.
The following table lists examples of such topics of interest, any relevant legislative or
administrative resources, any relevant CRS resources, and names of appropriate CRS experts for
the benefit of congressional clients. Besides the CRS reports listed below that provide
background on relevant topics, also see CRS reports on health provisions in recent COVID-19
legislation and a CRS report that provides more detail on COVID-19 testing issues, including
private health insurance coverage:
 CRS Report R46316, Health Care Provisions in the Families First Coronavirus
Response Act, P.L. 116-127,
 CRS Report R46334, Selected Health Provisions in Title III of the CARES Act
(P.L. 116-136), and
 CRS Report R46481, COVID-19 Testing: Frequently Asked Questions.
The information in this report is current as of its publication date and may be superseded by
subsequent congressional or administrative action. Congressional clients may contact the report
author and/or experts listed below for questions about further developments. In addition, CMS
guidance related to private health insurance and COVID-19 is compiled on its website.51

51 CMS, CCIIO, “Coronavirus Disease 2019 (COVID-19) Guidance,” accessed April 28, 2020, at
https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs#COVID-19.
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Table A-1. Resources for Further Questions About Private Health Insurance
FFCRA and CARES Act provisions are discussed in the reports listed in the Appendix

Key Federal Resources
CRS Resources
CRS Experts
Coverage of COVID-19 benefits by types of private plans not addressed in this report
Federal Employees
FFCRA §6006
CRS Report R43922, Federal
Noah Isserman
Health Benefits (FEHB)
Employees Health Benefits (FEHB)

Program
Program: An Overview
Catastrophic plans
CMS March 18 FAQa
CRS Report R44065, Overview of
Vanessa
Health Insurance Exchanges
Forsberg

Certain other health
Tri-Agency April 11 FAQc
CRS Report R46003, Applicability of
Vanessa
coverage

Federal Requirements to Selected Health
Forsberg
arrangementsb
Tri-Agency June 23 FAQd Coverage Arrangements

Other issues related to private coverage of COVID-19 benefits
Health savings account
IRS March 11 Noticee
CRS Report R45277, Health Savings
Ryan Rosso
(HSA) eligibility and

Accounts (HSAs)

high-deductible health
CARES Act §3701 and
plans (HDHPs)
§3702
Out-of-network
Tri-Agency April 11 FAQc
CRS Report R46116, Surprise Bil ing in
Ryan Rosso
coverage and surprise


Private Health Insurance: Overview and
bil ing
Tri-Agency June 23 FAQd
Noah Isserman

Federal Policy Considerations

HHS Provider Relief
Funding Terms and
Conditionsf

CARES Act §3202
Private coverage of certain benefits not addressed in this report
Mental health
N/A
N/A
Noah Isserman

(coverage)
Tri-Agency June 23 FAQd

Johnathan Duff
(service provision)
Telehealth
CMS March 24 Telehealth
CRS Report R46239, Telehealth and
Noah Isserman
FAQg
Telemedicine: Frequently Asked Questions
(coverage)


Tri-Agency April 11 FAQc
Victoria Elliott

(service provision)
Tri-Agency June 23 FAQd
Prescription drugs
CMS March 24
Consumer out-of-pocket drug costs
Noah Isserman
Prescription Drug FAQh
section of CRS Report R44832,

Frequently Asked Questions About
Prescription Drug Pricing and Policy

Private health insurance enrollment and premiums
Health insurance
Healthcare.gov COVID-
CRS Report R44065, Overview of
Vanessa
exchanges
19 pagei
Health Insurance Exchanges
Forsberg


Premium payments;
CMS March 24 Premium
CRS Report R44425, Health Insurance
Bernadette
premium tax credits
Payment FAQj
Premium Tax Credits and Cost-Sharing
Fernandez
and cost-sharing

Subsidies

subsidies
CMS August 4 Premium

Credit Guidancek
CRS Report R44392, The Health
Coverage Tax Credit (HCTC): In Brief

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Key Federal Resources
CRS Resources
CRS Experts
Loss of employment-
N/A
CRS In Focus IF11523, Health
Ryan Rosso
based coverage

Insurance Options Fol owing Loss of


Employment





CRS Report R40142, Health Insurance

Continuation Coverage Under COBRA



CRS Insight IN11448, CARES Act
Income Support and Unemployment
Compensation: Effect on Eligibility for
Medicaid, CHIP, and ACA Premium Tax
Credit

Source: Created by CRS.
Notes: This table is not meant to represent a comprehensive list of topics related to private health insurance
coverage and COVID-19. “FFCRA” is the Families First Coronavirus Response Act. “CARES Act” is the
Coronavirus Aid, Relief, and Economic Security Act. “CMS” is the Centers for Medicare & Medicaid Services.
“IRS” is the Internal Revenue Service. “Tri-Agency” refers to the Departments of Labor (DOL), Health and
Human Services (HHS), and the Treasury.
a. CMS, “FAQs on Catastrophic Plan Coverage and the Coronavirus Disease 2019 (COVID-19),” March 18,
2020, at https://www.cms.gov/CCIIO/Resources/Files/Catastrophic-Coverage-of-COVID-19.pdf.
b. The Tri-Agency April 11 FAQ notes the applicability of FFCRA requirements to certain types of plans not
addressed in this report, including nonfederal governmental plans, church plans, student plans, group health
plans covering fewer than two current employees (including “retiree plans”), and plans in their provision of
excepted benefits. It also addresses short-term, limited-duration insurance (STLDI). Background on some of
these coverage arrangements is provided in the CRS report noted above.
c. DOL, HHS, and Treasury, “FAQS ABOUT FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND
CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT IMPLEMENTATION PART 42,” April
11, 2020, at https://www.cms.gov/files/document/FFCRA-Part-42-FAQs.pdf.
d. DOL, HHS, and Treasury, “FAQS ABOUT FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND
CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT IMPLEMENTATION PART 43,” June
23, 2020, at https://www.cms.gov/files/document/FFCRA-Part-43-FAQs.pdf.
e. IRS, “HIGH DEDUCTIBLE HEALTH PLANS AND EXPENSES RELATED TO COVID-19,” March 11, 2020,
at https://www.irs.gov/pub/irs-drop/n-20-15.pdf.
f.
HHS, “Acceptance of Terms and Conditions,” accessed April 22, 2020, at https://www.hhs.gov/sites/default/
files/relief-fund-payment-terms-and-conditions.pdf.
g. CMS, “FAQs on Availability and Usage of Telehealth Services through Private Health Insurance Coverage in
Response to Coronavirus Disease 2019,” March 24, 2020, at https://www.cms.gov/files/document/faqs-
telehealth-covid-19.pdf.
h. CMS, “FAQs on Prescription Drugs and the Coronavirus Disease 2019 (COVID-19) for Issuers Offering
Health Insurance Coverage in the Individual and Smal Group Markets,” March 24, 2020, at
https://www.cms.gov/files/document/faqs-rx-covid-19.pdf.
i.
Healthcare.gov, “Marketplace Coverage & Coronavirus,” accessed April 21, 2020, at
https://www.healthcare.gov/coronavirus/. In addition, some organizations are tracking state-based
exchanges’ decisions to open special enrol ment periods. For example, see National Association of
Insurance Commissioners (NAIC), “State Bul etins and Alerts,” “Life and Health Chart,” accessed April 21,
2020, at https://content.naic.org/naic_coronavirus_info.htm.
j.
CMS, “Payment and Grace Period Flexibilities Associated with the COVID-19 National Emergency,” March
24, 2020, at https://www.cms.gov/files/document/faqs-payment-and-grace-period-covid-19.pdf.
k. CMS, “Temporary Policy on 2020 Premium Credits Associated with the COVID-19 Public Health
Emergency,” August 4, 2020, at https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-
Marketplaces/Downloads/Premium-Credit-Guidance.pdf.

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Author Information

Vanessa C. Forsberg

Analyst in Health Care Financing


Acknowledgments
Multiple CRS analysts provided review and comments on this report, or wrote content in other reports that
was adapted or cited for this one, including Bernadette Fernandez, Sarah A. Lister, Ryan Rosso, Kavya
Sekar, Noah Isserman, Amanda K. Sarata, Agata Dabrowska, Johnathan Duff, Victoria L. Elliott, and
Jennifer A. Staman.

Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan
shared staff to congressional committees and Members of Congress. It operates solely at the behest of and
under the direction of Congress. Information in a CRS Report should n ot be relied upon for purposes other
than public understanding of information that has been provided by CRS to Members of Congress in
connection with CRS’s institutional role. CRS Reports, as a work of the United States Government, are not
subject to copyright protection in the United States. Any CRS Report may be reproduced and distributed in
its entirety without permission from CRS. However, as a CRS Report may include copyrighted images or
material from a third party, you may need to obtain the permission of the copyright holder if you wish to
copy or otherwise use copyrighted material.

Congressional Research Service
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