Employer Group Plan Provisions | Fully Insured FAQ
In light of the current events surrounding COVID-19 and decisions employer groups have before them, PacificSource has created the following FAQ to address concerns and questions. We will continue to monitor the situation and make adjustments to our policies. These initial changes are being made quickly to assist our customers.
Expanded Provisions for COVID-19
PacificSource is waiving member costs for COVID-19 testing and diagnosis regardless of place of care for all fully-insured members. Please note that treatment of COVID-19 provided by an out-of-network provider may result in balance billing for members since we are waiving member cost share up to our allowed amount.
PacificSource covers antibody testing for members; member costs are waived (i.e., no copays, deductibles, or coinsurance) through December 31, 2021, when:
- The test is requested by a qualified healthcare provider, and
- The test is medically appropriate for treatment of the individual patient as determined by the healthcare provider under accepted standards of medical practice, and
- The test meets the criteria for coverage under the Families First Coronavirus Response Act of 2020, as amended, and
- The test is processed by a laboratory that is authorized to perform SARS-CoV-2 serological testing.
We are not covering antibody testing for reasons related to public health and epidemiological study to inform public health authorities and policymakers during the pandemic (i.e. “Crush the Curve” in Idaho).
No, PacificSource will not cover antibody testing as this would not be medically necessary nor medically indicated by the guidelines promulgated by the Centers of Disease Control (CDC), United States Food and Drug Administration (US FDA), the Infectious Disease Society of America (IDSA). In addition, the US Equal Employment Opportunity Commission (EEOC) has outlined that any mandatory medical test is job related and consistent with business necessity. For more information see section A.6 of the EEOC notice.
No, there is not a state agency mandate that requires employee antibody testing prior to returning to work.
No, PacificSource will not cover antibody testing as this would not be medically necessary nor medically indicated by the guidelines promulgated by the CDC, US FDA, the Infectious Disease Society of America (IDSA).
COVID-19 Vaccine Information
As authorized through the CARES Act, the vaccine itself will be paid for by the federal government. Costs for administering vaccinations will be paid by PacificSource for fully insured plans, and by employer groups for self-funded plans.
According to the CDC, all employer group plans, including grandfathered plans, are required to cover the administration, without cost sharing, of the COVID-19 vaccine no later than December 28, 2020.
No. Providers may not balance bill patients for costs associated with COVID-19 vaccine administration.
During the Public Health Emergency period for COVID-19, cost sharing is prohibited at out-of-network facilities. After the emergency expires, out-of-network cost shares will apply.
For COVID-19 vaccines administered in network, the plan will pay the negotiated rate.
For vaccines administered out of network, the reimbursement rate to providers will be based on a reasonable cost as determined by prevailing market rates, typically based on the Medicare rate.
According to the Department of Health and Human Services, the rates are as follows:
- Single-dose administration: $28.39
- Two-dose administration: first dose $16.49, second dose $28.39
- These rates will be geographically adjusted.
Vaccine administration is covered under the medical plan when given by a medical provider, and under the pharmacy benefit when given by a pharmacy.
Please consult with your legal counsel or refer to OSHA for guidance.
Yes. As authorized through the CARES Act, the vaccine itself will be paid for by the federal government. Costs for administering vaccinations will be paid by PacificSource for fully insured plans, and by employer groups for self-funded plans.
Reduction in Hours
No, PacificSource will allow you to reduce your minimum hours per week requirement March 1, 2020, through December 31, 2021.
No, PacificSource does not need to be notified of reduction of hours for the time period March 1 through December 31, 2021.
No, not if the employee was deemed ineligible under the original policy. The hours-worked eligibility waiver is only for current actively enrolled employees March 31, 2020, through December 31, 2021.
Leave of Absence / Layoff / Furlough
Washington, Idaho, and Montana: No, the employee will not need to satisfy a new probationary period if returning to work within 6 months of a layoff or within 6 months for a leave of absence.
Oregon: No, the employee will not need to satisfy a new probationary period if returning to work within 6 months for a leave of absence or within 9 months for a layoff.
Yes, PacificSource will allow you to continue to pay for and keep your furloughed employee covered under the group health plan if the employee was actively enrolled on the group health plan prior to the furlough.
An employee can continue furloughed group health plan coverage for 12 weeks provided premium coverage is received for the coverage period.
Yes, group health plan coverage would terminate at the end of the month following the 12-week furlough.
Yes, if the furloughed employee’s group health plan coverage is terminated, the employee would be offered COBRA/State Continuation or be eligible to apply for an individual policy.
No, PacificSource does not need to be notified unless the employee does not return to work after 12 weeks.
Yes, as long as the employee had returned to work, the second furlough would be eligible for 12 weeks of group health coverage.
Termination of Coverage
Yes, as long as premium was received for the current month in which it was due.
Do you still have at least 1 active employee? If not, do not offer COBRA. If yes, continue to the next answer.
Yes, if you are an employer that had at least 20 employees on more than 50 percent of your typical business days in the previous calendar year. Both full- and part-time employees are counted to determine whether a plan is subject to COBRA.
All states: Your employees are eligible to enroll in an individual plan if their loss of coverage is involuntary and/or meets special enrollment provisions.
In Oregon, if you have fewer than 20 employees, or if your group is not subject to the continuation of coverage provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) as amended, you may be able to continue your coverage for up to nine months.
In Washington, state continuation may be available when your group is not required by federal law to offer COBRA or when enrollees are not eligible for COBRA for three months.
To determine eligibility, please refer to the following links:
- Oregon: Oregon.gov/oha/HSD/OHP/Pages/Apply.aspx
- Washington: HCA.wa.gov/health-care-services-supports/apple-health-medicaid-coverage/eligibility
- Montana: DPHHS.mt.gov/montanahealthcareprograms/memberservices
- Idaho: HealthandWelfare.Idaho.gov/FoodCashAssistance/ApplyforAssistance/Applyforservices/tabid/1555/Default.aspx. Apply online at: https://idalink.idaho.gov/
PacificSource will temporarily extend the reinstatement period from 15 days to 30 days. This will be allowed through December 31, 2020.
Common Law Employee
Yes, your group health plan coverage will continue until your next policy renewal.
Premium Payments
No, not at this time. PacificSource has extended the grace period from 30 days to 60 days for March and April 2020 to allow greater payment flexibility.
Yes, PacificSource has extended the grace period to 60 days for March through September 2020 bills. For example, bills due on June 1 will have 60 days to remit payment. The grace period is a one-time event, not continuous. A group may enter a grace period and then become current with payments. If that group becomes delinquent after this period, the group will not be allowed another grace period.
Telehealth Services
Telemedicine is a telephonic, skype or two way video synchronization consult with a local health care professional. Teladoc is a PacificSource vendor partner that provides telephonic, skype of two way video synchronization consultation. For both telehealth and Teladoc there are specific procedure codes that are used for the consult based on the time duration of the consult.
As mentioned above, telemedicine and Teladoc will use specific codes that reflect the duration of the consult.
PacificSource covers a broad array of physician and behavioral health services that would normally be performed in the office and are paid at the same rate as an in person visit, subject to the group health plan benefits and applicable member cost share. COVID-19 related telephone visits are not subject to the member cost share provided the claim includes the appropriate COVID-19 diagnosis codes.
For COVID-related services, the member cost share has been waived as long as the claim is for one of the COVID-related service codes. Other applicable telehealth services will be subject to the plan benefits, including applicable deductibles, copayments, and coinsurance.
The IRS guidance (Notice 2020-15) released in March allows the HDHP to provide benefits without first meeting the deductible for COVID-19 testing and treatment. Telehealth services would be treated the same as in-person visits. PacificSource believes there will be further regulatory guidance allowing all cost share to be waived for telehealth visits on all health plans including HSA eligible plans.
UPDATE: 5/13/2020 – Notice 2020-15 clarifies that the relief regarding HDHPs and expenses related to testing and treatment of COVID-19 applies to expenses incurred on or after 1/1/2020. It also clarifies that the panel of diagnostic testing for influenza A&B norovirus and other coronaviruses and respiratory syncytial virus (RSV) and any items or service required to be covered with zero cost sharing under the Families First and CARES Acts. The CARES Act provides a temporary safe harbor for HDHPs to allow first dollar coverage for these services through tele-health and other remote site-of-care visits for plan years 2020 and 2021.
Details of Notice 2020-15 and requirements can be found here: https://www.irs.gov/pub/irs-drop/n-20-15.pdf
Teladoc® Services
Teladoc is our contracted telehealth services vendor for all of our fully insured medical plans. PacificSource and Teladoc have been working to ensure the highest level of member experience possible during this current environment before us. The following questions and answers are specific to services provided by Teladoc.
Their cost share will be waived for services, including general medical and behavioral health through December 31, 2021.
The member cost share override was effective March 13, 2020, and implemented March 21, 2020.
The Teladoc member cost share override will remain in place until December 31, 2021.
Teladoc will reimburse the member in the same form of payment that was made.
PacificSource is waiving the member Teladoc cost share regardless of the diagnosis during the override period of March 13, 2020 – December 31, 2021.
The IRS guidance (Notice 2020-15) released in March allows the HDHP to provide benefits without first meeting the deductible for COVID-19 testing and treatment. Telehealth services would be treated the same as in-person visits. PacificSource believes there will be further regulatory guidance allowing all cost shares to be waived for telehealth visits on all health plans, including HSA-eligible plans.
Helping to Ease Strain on Providers
We’ve taken two important measures to ease help the current strain on providers and their facilities while bolstering access to care:
- To reduce the administrative burden on provider offices, we’ve suspended authorization and referrals through June 30, 2020.
- To encourage members to receive care without leaving home, we’ve expanded telehealth services. Telehealth appointments related to COVID-19 testing and diagnosis are no cost to members.
Special Enrollment Period
Yes, in accordance with ERISA Section 518, Extension of Certain Timeframes for Employee Benefit Plans, we will extend the enrollment notification period to extend to 60 days after the announcement of the end of the COVID-19 National Emergency or such other date announced by the Department in a future notice.
A member has a baby and would typically have 60 days from the date of birth to notify us to add the newborn to the plan. With the Extension of Certain Timeframes, the member would have up to 60 days after the end of the COVID-19 National Emergency or such other date announced by the Department to add the newborn.
Mid-year Plan Changes
Yes, PacificSource will allow small employer groups to make changes to their health plan benefits one time through December 31, 2020, subject to the following criteria, with the exception of small employer groups in Washington.
- Waive 4 week advance notification requirement
- Plan changes would be effective the first of the following month
- Plan changes are only allowed for a benefit reduction (not benefit increases)
- Rates and plan options will be based on the last renewal/quote.
- Requires everyone enrolled to switch over to the new plan, this does not constitute an open enrollment or an opportunity to add additional plans.
- If plan/benefit change is within 90 days of renewal, sales will communicate to the broker/group that upcoming renewal will likely show the prior plan renewal as the current plan. (i.e. not the reduced plan)
At the request of the employer group or agent, Sales will need to inform Underwriting of any plan changes referenced above.
Small employer groups in Washington will need to cancel their current coverage and request a quote for new coverage. In doing so, they will be subject to the new rates associated with the plan and will have a new renewal date.
PacificSource is not changing our process. If the group health plan is rated with age bands they will continue to be rated with age bands at renewal. For mid-year plan changes, we are not recalculating renewals. If a group would like to make a mid-year plan change, we will refer to the rates that were issued at the last renewal or sale and the plan designs that were available to them.
No, a mid-year plan change does not constitute an open enrollment period for employees who had previously waived to come on the group health plan.
No, if a group would like to offer a lower cost group health plan option, they would need to replace an existing plan.
Yes, an employer may choose to move from Voyager to one of our more competitively priced Navigator/SmartChoice products.
Small group – Yes. A small employer groups can change their medical plan employer contribution to no less than 50%. Underwriting must be notified of any changes in employer contributions.
Large group – No. Employer contributions are a rating factor so PacificSource would not consider changes in contribution strategy off of renewal.
Dental – No. Employer contributions are a rating factor so PacificSource would not consider changes in contribution strategy off of renewal.
Benefit Payments
PacificSource will process the claims as in-network, subject to the out of network allowable. In cases where surprise billing is applicable, the claim will be priced according to the surprise billing fee schedule. In cases where surprise billing is not applicable, we will send claims to our network pricing partner Zelis to see if there is an opportunity for repricing.
Yes, in accordance with ERISA Section 518, Extension of Certain Timeframes for Employee Benefit Plans, we will extend the notification period to extend to 60 days after the announcement of the end of the COVID-19 National Emergency or such other date announced by the Department in a future notice.
Yes, in accordance with ERISA Section 518, Extension of Certain Timeframes for Employee Benefit Plans, we will extend the notification period to extend to 60 days after the announcement of the end of the COVID-19 National Emergency or such other date announced by the Department in a future notice.
Yes, in accordance with ERISA Section 518, Extension of Certain Timeframes for Employee Benefit Plans, we will extend the notification period to extend to 60 days after the announcement of the end of the COVID-19 National Emergency or such other date announced by the Department in a future notice.
Yes. Beginning January 1, 2021, PacificSource will resume our standard practice of requiring prior authorization (PAs) including inpatient notifications for all members and all lines of business. This will include advanced imaging and genetic testing authorizations processed through AIM. To determine if a service requires prior authorization, consult our Prior Authorization Grid: https://authgrid.pacificsource.com/