Group Health Plan Requirements Extended

: Written by: John E. Falcone; Published: November 02, 2022

The Biden administration on Oct. 13 extended the COVID-19 public health emergency for an additional 90 days, keeping emergency measures in place through Jan. 11. The public health emergency declaration is important to group health plan sponsors because it determines the period during which group health plans and insurers must pay for Covid-19 tests and related services without charging cost-sharing. The coverage requirements apply to payment through both medical plans and pharmacy benefits. As long as the public health emergency is in place, when preventive services such as COVID-19 tests and vaccines are delivered by an out-of-network health care provider, employer plans must reimburse the provider a "reasonable amount," as determined in comparison to prevailing market rates for such services.

Other health plan requirements, most notably the requirement to extend certain deadlines related to COBRA, special enrollment, and claims and appeals are pegged to a different COVID-19 emergency declaration (the “national emergency”) that was declared in March 2020. Keeping the national emergency in place means that the extended deadlines listed below were continued through February 2023 (or, if earlier, 60 days from the end of the national emergency):

COBRA qualifying event and disability extension notices. The 60-day deadline by which qualified beneficiaries must notify the plan of certain qualifying events (e.g., divorce or legal separation, a dependent child ceasing to be a dependent under the terms of the plan) or disability determination.
COBRA election. The extended 60-day deadline to elect COBRA continuation coverage.
COBRA premium payments. The 45-day (for the initial payment) and 30-day (for subsequent payments) deadlines to timely pay COBRA premiums.
HIPAA special enrollment period. The 30-day deadline (in some instances, 60-day) to request enrollment in a group health plan following a special enrollment event (i.e., birth, adoption or placement for adoption of a child, marriage, loss of other health coverage, or eligibility for a state premium assistance subsidy).
Benefit claims and appeals. The deadline under the plan by which participants may file a claim for benefits (under the terms of the plan) and the deadline for appealing an adverse benefit determination.
External review. The four-month period (for the federal external review process; this period could be different for a state external review process) for a claimant to file a request for external review.
Perfecting a request for external review. The four-month period (or 48-hour period following receipt of an incomplete request notification, if later) for a claimant to perfect an incomplete request for external review.