Can They Do This? Generally, there is a general prohibition on midyear coverage modifications. However, the CMS announced that it would not take enforcement action against health insurers that amend group or individual products midyear to provide greater coverage for telehealth services or to reduce or eliminate cost-sharing requirements for telehealth services. This applies even if the telehealth services covered by the change are not related to COVID-19. CMS will continue to take enforcement action against health insurers that attempt to limit or eliminate other benefits to offset the costs of more generous telehealth benefits. What about Self-Funded Plans Self-funded plans are considered “insurers,” so the decision to promote telehealth services would apply directly to any self-funded employer plans. The CMS guidance does not directly apply to self-insured ERISA plans, which are under Department of Labor (DOL) jurisdiction and are not subject to the ban on midyear modifications. What Action is Necessary? Many insurers and self-funded plans are making these types of plan modifications to their health plans to benefit employees. It is important to provide communication to employees so that they can avail themselves of these benefits. It is recommended to provide both informal communication (so that employees know the benefits are there) and formal communication (so that benefit plans remain compliant). See below for additional information on the required formal plan documentation.
Employee Rx Concerns The uncertainty of times today has caused many employees considerable stress and anxiety about maintaining continuity in taking their prescription drugs. Will I be able to refill my prescription? What if I can’t get out to the store? What happens if I run out of my medication? In the wake of COVID-19, these concerns are valid. The following section outlines actions taken by the pharmaceutical industry to ease employee concerns. Rx Industry Response The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS), along with numerous state and local authorities have issued both guidance and directives for Pharmacy Benefit Managers (PBMs) and health plans. We have seen swift response and proactive compliance from essentially all insurance carriers and PBMs. The pharmaceutical industry has responded quickly to meet the needs of members during this unprecedented time. The following are some of the key initiatives that most PBMs companies have implemented for the benefits of employees and their families. Ensuring Drug Availability Companies are lifting the refill-too-soon restrictions for medications. This allows employees to obtain an extra supply of their prescription medications (so long as they have refills remaining at a retail or mail-order pharmacy). Prior Authorization Relaxed Existing prior authorizations for chronic condition medications that are set to expire on an imminent basis are being extended for, typically, 90 days. This is intended to ensure that convenient access to critical medications is maintained and any hassle factor is eliminated.
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