Frequently asked questions for agents
Last updated 10/7/2022
Information provided by Priority Health is for educational purposes only and is not intended as legal advice. The information provided is based on regulations and legislation, which are updated frequently. Please consult your benefits attorney with any legal questions.
OSHA's COVID-19 Emergency Temporary Standard
- November 5, 2021 - rule effective
- December 5, 2021 - Employers must provide employees with time off to get vaccinated
- January 4, 2022 - Employees of large employers must be vaccinated or submit to weekly testing
The ETS applies to employers with a total of 100 or more employees at any time the standard is in effect. Employers must count all of their employees across all of their U.S. locations regardless of their current COVID-19 vaccination status, regardless of where they perform their work (i.e. in-person, remotely, etc.), and regardless of their employment status (i.e. temporary/seasonal workers employed anytime while the ETS is in effect, part-time workers, minors; independent contractors do not need to be counted). More details are included in the Department of Labor FAQ linked below.
The ETS requires covered employers to adopt written mandatory vaccination policies for their workplaces or adopt a written policy which allows employees to undergo regular COVID 19 testing and wear a face covering at work in lieu of vaccination.
OSHA will continue to monitor trends in COVID-19 infections and death as more of the workforce and the general population become fully vaccinated against COVID-19 and the pandemic continues to evolve. Where OSHA finds a grave danger from the virus no longer exists for the covered workforce (or some portion thereof), or new information indicates a change in measures necessary to address the grave danger, OSHA will update this ETS, as appropriate.
Covered employers are required to support COVID 19 vaccination by providing reasonable time to each employee who chooses to get vaccinated during work hours for each of their primary vaccination dose(s). This means providing up to a total of four hours of paid time, at the employee’s regular rate of pay, for time spent getting vaccinated during working hours (including time spent traveling to the vaccination site, registration time, etc.).
The ETS does not require employers to pay for any costs associated with testing. However, employer payment for testing may be required by other laws, regulations, or collective bargaining agreements or other collectively negotiated agreements. OSHA notes that the ETS also does not prohibit the employer from paying for costs associated with testing required by the ETS. Otherwise, the agency leaves the decision regarding who pays for the testing to the employer.
Employees will be required to have weekly tests until they are fully vaccinated or the ETS is no longer in effect.
No, public health surveillance testing or employee screening are not considered medically necessary and therefore not covered.
COVID-19 testing coverage
No, public health surveillance testing or employee screening are not considered medically necessary and therefore not covered.
- At-home tests from the federal government shipped to your home: Starting Jan. 19, 2022, all members can order free rapid tests shipped to their home at covidtests.gov. This cost does not flow through the health plan nor back to our self-funded employers. This is completely covered by the government.
- At-home tests purchased from a pharmacy or retailer: As of Jan. 15, 2022 FDA approved over-the-counter at-home tests covered 100% for all commercial members (including HSA plans before deductible) who have pharmacy coverage with Priority Health. 8 tests (4 kits of 2 tests each) are covered per individual per 30 day period without a prescription from a health care professional. This means a family of four, all on the same plan, can purchase up to 32 of these tests covered 100% by their health plan, per month. Pharmacies and retailers must be within the Priority Health network and tests must be FDA approved. The list of approved tests is located here.
- Diagnostic tests ordered by a health care professional: For all members, including Commercial Group, Individual, Medicare, and Medicaid membership, as well as HSA plan members, as part of the Families First Coronavirus Response Act, the cost of COVID-19 diagnostic testing and the administration of the test such as office visits, blood draws, or specimen handling are covered 100%, with no member cost sharing applied. Applies to in-network and out-of-network providers. COVID-19 diagnostic testing is covered when the test is medically necessary to diagnose and treat a patient’s symptoms.
Tests are not covered for public health surveillance testing or employee screening for the workplace.
COVID-19 testing: Over-the-counter
COVID-19 OTC tests purchased on or after Jan. 15, 2022, will be covered under the pharmacy benefit. Any employer that has their pharmacy benefit administered through another benefit administrator will need to work directly with their administrator.
OTC tests will be covered at the point of sale through our pharmacy benefit manager, Express Scripts Intl (ESI). Through ESI’s network of pharmacies, members can bring their test to the pharmacy counter and have them bill it to their insurance. If members encounter any issues, they can submit this form for test reimbursement.
Members will need to complete our COVID-19 OTC form and attach the original receipt dated on or after Jan. 15, 2022, the UPC barcode from the test kit package, along with following the instructions on the form. Information should be sent directly to ESI by mail or fax.
The member can expect to receive reimbursement within 6-8 weeks. The payment will come in the form of a check issued to the health plan subscriber even if the kits were purchased for covered members on the plan. If members have any questions about their reimbursement, they should call the customer service number on the back of their ID cards.
Members are able to obtain a COVID-19 OTC test directly from a participating pharmacy. The member will need to show their Priority Health member ID card at the point of purchase and will need to purchase it through the designated pharmacy window.
The guidance requires members have access to 8 individual over-the-counter tests within a 30-day period without a prescription from a health care provider. The kits are typically sold in 2 individual tests per kit, so the limit of kits per member is 4.
Reimbursement is limited to $12 per test for tests purchased from a non-preferred pharmacy, or other retailer.
Members will find the details posted here. Because these regulations and processes keep evolving, it’s important to have a dedicated page that can be updated quickly. We don’t want to confuse members by pushing out information that could quickly be outdated. Our Customer Care center and member portal also direct members to this page.
COVID-19 virtual care and treatment
For virtual care related to COVID-19 diagnostic tests and the administration of the test: members are covered 100%, for fully funded and self-funded employers, as part of the Families First Coronavirus Response Act.
Members with High Deductible Health plans also receive $0 virtual care before deductible.
For all other virtual care:
- Between the dates of March 19-June 30, members were provided with limited virtual care (codes: 99441-99443, 99421-99423 and 98970-98972) covered at $0 copay. Many self-funded plans reverted to regular member cost share on May 1, 2020.
- Between the dates of July 1 and December 31, 2021, we are expanding $0 virtual care services to include all types; medical and behavioral health services. This applies to all fully funded commercial plans including HDHP plans. Employer plans that are self-insured determine benefit coverage for their employees and dependents at their discretion.
- Beginning January 1, 2021, our standard benefit offering continues to include $0 virtual care services for fully funded plans. Among large and small groups there are still variations of benefit coverage, for example, grandfathered plans, union negotiations, non-standard plans, etc. Employer plans that are self-insured determine benefit coverage for their employees and dependents at their discretion.
No, amounts paid by the plan will not accumulate toward the member deductible, coinsurance maximum, or TrOOP accumulators.
In non-emergent situations, care provided by an out-of-network provider will be covered at the alternate or out-of-network benefit level on POS and PPO plans, including member cost-sharing. As always, emergency care, including hospitalizations, are covered as in-network, regardless of the provider’s participation status. Services rendered by field hospitals, temporary clinics, or in a non-traditional/overflow setting will be considered emergent care and covered in-network. If a patient must be transferred to an out-of-network facility due to capacity issues, that care will be covered as in-network. Priority Health will work with our providers partners throughout the state to ensure that members are not balance billed due to receiving care at an out-of-network provider during this time.
CMS has issued guidance to providers on specific codes that should be used to identify claims related to COVID-19 treatment. This is universal, not specific to an individual health plan. Priority Health will use this information to determine which claims will be paid in full. We expect many claims will be for emergency department visits, observation care, and inpatient stays.
No, Priority Health coverage decisions will apply to our members regardless of where they live. While Priority Health utilizes Cigna’s national network for our members that reside outside of Michigan, Priority Health makes all benefit decisions impacting our members.
There is a notification on the home page that links to constantly updated coverage information for Priority Health members. This microsite is the best place for members to find the most up-to-date information on coverage. Members can also call the customer service number on the back of their ID card.
Priority Health is already allowing early refills for our members that have 30 day prescriptions, and encouraging members to switch to 90 day prescriptions where possible. Early refills on 30 day prescriptions are not available on controlled substances, or specialty medications filled through a specialty pharmacy. Applicable member copays and cost sharing apply to all medication fills. This executive order also allows pharmacists the ability to substitute therapeutically equivalent medications without prescriber approval if there are critical shortages.
CVS, Walgreens and Meijer offer free in-home delivery of prescriptions for all Priority Health plans. Members can get more information in the member FAQs. If members already have an automatic 90-day refill set up, then there is no need to change a thing. They get discounted rates and their prescriptions delivered to their home already.
All COVID vaccines, including boosters, will be covered under the Priority Health Preventive Guidelines based on recommendation of the United States Preventive Services Task Force or recommendation from the Advisory Committee on Immunization Practices (ACIP).
The Federal Government will be covering the cost of the vaccine for each individual, however the administrative fee for the vaccine will be the responsibility of the health plan or self- funded employer group, as well as grandfathered and retiree commercial plans. Plan documents can be referenced for coverage details.
The estimated cost of an administration could vary from $17-$40 dollars per dose. The current approved vaccines require 2 doses. The administration of the vaccine is covered under a plan’s preventative benefit.
If a COVID vaccine is not billed separately from an office visit and the primary purpose of the office visit is solely for the vaccine, the health plan and self-funded employer group are required to waive any cost sharing requirements with respect to the office visit.
Any medical care to treat an adverse reaction to the vaccine will be covered under plan and follow standard plan benefits.
Both vaccines are considered mRNA vaccines meaning neither use the live virus that causes COVID-19. Please discuss your options with your health care provider who will recommend which vaccine is best for you.
That decision is solely for an employer to decide. We recommend that you seek legal advice from your benefit attorney.
We will not be administering an exclusion of an illness brought on by COVID. The illness that occurs with COVID disease is covered under our benefits offering, similar to any other disease and illness.
Group population vaccination status reports are available from your Priority Health account manager upon request.
Yes, employers are permitted to subsidize COBRA. However, if the subsidy ends before the maximum COBRA coverage period, that may not be considered a qualifying event for the employee to enroll in Individual Marketplace coverage outside of the open enrollment period. To avoid a lapse in coverage, the employee would be required to pay the entire cost of the COBRA premium until they are able to enroll in Individual coverage.
No, COBRA continuation coverage is available only to "qualified beneficiaries" and only after a qualifying event has occurred. COBRA defines "qualified beneficiaries" as an employee who was covered by a group health plan on the day before a qualifying event occurred. If the employee was not covered on the health plan when the lay-off occurred, they are not eligible for COBRA.
Collecting unemployment does not affect the employer's ability to offer health benefits during this time.
Yes, if an employee is laid off before they meet the group's new hire waiting period, they will be eligible to begin coverage as of their planned effective date, provided the employer still considers laid off employees as "active" for benefits purposes.
Employer groups may continue to utilize our standard enrollment spreadsheet for making coverage changes during this time.
Employees that are no longer paying for child care may, but are not required to, change their election. The change in election must be consistent with the reason, e.g. if a child is no longer in care, the election could be reduced or eliminated. Enrollment forms for flexible spending plans can be found in the Priority Health Agent Center. Members with flexible spending or health savings accounts administer by our partner, HealthEquity, can access additional information on their website.
While Priority Health encourages, and is providing the flexibility to our employers, to continue coverage for employees during any layoffs resulting from temporary business closures due to COVID-19, we understand that will not be possible for all employers. If a group must terminate coverage during this time period, Priority Health will waive any applicable waiting periods if the employee returns to work within 6 months. An employer can decide if they want to enact a shorter waiting period, but must apply that to all employees.
No, accumulators will remain with the member under the same plan, for the remainder of the plan year. Accumulators don’t automatically transfer between HSA and non-HSA plan types. It would need to be done manually.
Due to the state of emergency we are not requiring any changes to your plan documents at this time. We will continue evaluate this as the situation continues to evolve.
Premium and administrative information
Self-Funded groups pay for all their members medical and pharmacy claim cost so the impact to the lower than projected utilization will be realized immediately in their weekly funding.
The credit will show at the bottom of the invoice noted as “Premium credit due to COVID-19” with a dollar amount.
Priority Health will not be making an adjustment to premium but reflecting this as an adjustment to the total amount due. A group can continue to pay the full premium amount reflected on the invoice and the credit will just roll over to their next billing cycle.
The group credit will not impact agent commission on group business.
Priority Health will follow our current process for alerting our self-funded groups of inpatient admissions and potential high-cost cases.
While an employer group could choose to shift premium costs in part or in whole to their employees, any group considering this approach should absolutely consult with their benefits attorney. As a reminder, terminating employee coverage due to failure to pay premium is not a COBRA qualifying event, nor does it provide the employee with an SEP for Individual coverage.
Employers may need to provide information on health care premiums for up to 24 months. Some individual lenders may request copies of invoices be provided. Employer groups, or their designated agent, may access historical invoices through their Priority Health employer center. If the employer or agent do not have access to the portal, a report will be provided upon request supplying this information, or copies of invoices if required by the lender. Please email your group name, group number, and the time period for reporting to PH-PremiumManagement@priorityhealth.com. Allow 1-2 business days for a billing receipt summary report, and 2-3 business days for copies of invoices.
Priority Health's legal counsel has determined that modifications to our plan documents are not required at this time. Our SBCs do not call out specific diagnostic test coverage (e.g. influenza testing). Our plan documents (Certificates of Coverage, Insurance Policies, and Summary Plan Descriptions) each have sections addressing the fact that our plans all comply with applicable state and federal law, and in any instance where the plan document does not comply with applicable law or regulation, it will be deemed amended to the extent necessary to comply with such law.
An employer's status as an applicable large employer (ALE) is based on the sum of its full-time employees and its full-time equivalent employees for the prior calendar year, regardless of plan year.
For example, an employer has 55 employees today. Due to temporary closures or COVID-19 related workforce reductions, their workforce drops to 25 for the months of March and April. Next year, they will calculate their workforce as follows:
55 employees for 10 months of the year = 550
20 employees for March and April = 40
(550 + 40) / 12 = 49 employees
Our standard grace period is 30 days from the due date of the invoice. If you are concerned about your ability to pay your premiums, please reach out to your account manager or the Small Business Sales team to discuss payment options prior to the due date.
Employee coverage options
Yes, employers can continue to provide benefits and should keep the employees status as "active", should employers choose to do so. This "active" status is effective through Mar. 31, 2021. Reminder: an employer must be consistent with what options they offer to all similarly situated employees.
The following conditions apply to temporary active status:
- The extension of “active” coverage does not apply to terminated employees, nor is it a replacement for COBRA continuation.
- Employees in other categories like seasonal workers, disability and independent contracts remain not eligible for coverage.
- Priority Health reserves the right to audit eligibility of covered individuals. If an individual is found to be ineligible for temporary continuation, coverage will be terminated to the last date of active eligibility, and premiums will be forfeited.
- Employers are responsible for ensuring consistent application of this extension for all similarly situated employees.
- Employers are responsible for remitting the full amount of premium for any “active” employees and COBRA members.
Every individual’s needs will be different however, for many people the Marketplace will be less expensive than COBRA, especially if they are unemployed. To enroll on the Marketplace, enrollees just need to approximate their 2020 income on their application. If an employee takes COBRA for one month and it exhausts they would then be eligible for an SEP because the enrollee would be deemed 'newly eligible for assistance'. The effective dates are applied as outlined above.
In addition, if the member is currently enrolled in COBRA and cannot afford to continue that coverage they can use their new eligibility to enroll on the Marketplace or directly through Priority Health.
IRS Notice 2020-29
The IRS has recently released guidance (Notice 2020-29) allowing health plans flexibility to let participants make mid-year changes to health, FSA, and dependent care plans outside of a regular open enrollment period, and without a qualified life event.
Employees may choose to drop their current coverage, elect coverage if they have previously waived, add or remove eligible dependents, or move from one plan offering to another, if their employer offers multiple benefit plans. Employees may also newly elect, drop, or change contributions for flexible spending and dependent care accounts.
Priority Health is not offering large group plans the option to make mid-year changes to their plan design at this time, or add new plan offerings.
No, groups may choose to opt in. The Notice does not require that groups open their enrollment mid-year for elections without a qualifying event (such as marriage or birth).
No, an employer may limit the types of election changes allowed. For example, an employer may choose to allow only changes in election that provide an increase level of benefit, e.g. changing from self-only to family coverage, or changing from a plan that only offers in-network coverage to a plan that offers both in and out-of-network coverage. If an employees are allowed to drop coverage, the employer must receive an attestation in writing from the employee stating that they are or will immediately enroll in other comprehensive health coverage.
The Notice is applicable to employer-sponsored coverage offered through a section 125 cafeteria plan. This includes small and large employer groups, grandfathered and non-grandfathered plans, and all funding arrangements.
The open enrollment window will be determined by the employer. All changes must be for a prospective (future) effective date. For example, an employer may choose to open enrollments on May 18 for a two week time period, with an effective date of June 1. Priority Health will allow groups to offer one mid-year open enrollment.
Priority Health provides deductible credit mid-year when an employee moves to a like plan type. For example, an employee moving from a $4,000 deductible HSA to a $2,000 deductible HSA would receive credit for deductible amounts met during the current plan year. An employee that moves from a $2,000 Traditional HMO plan to a $2,000 Traditional POS plan would receive deductible credit. An employee moving from a plan with an embedded deductible (such as a Traditional or Tiered Copay plan) to a plan with an aggregate deductible (such as an HSA) or vice versa would NOT receive deductible credit.
Employees should work with their employer and HSA banking administrator to adjust contribution levels, to avoid penalties for exceeding contribution limits.
Yes. Employees may change the amount they contribute to their FSA during this period. This may be important for families who contribute the maximum to their dependent child care FSA if their daycare program is closed due to the pandemic. Similarly, employees who planned elective procedures for 2020 may wish to lower the amount in their healthcare FSA if the have delayed their elective procedure due to COVID-19.
DOL, IRS and Treasury Department Joint Notice
The Joint Notice announces the extension of certain time frames under the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code for group health plans, disability and other welfare plans, pension plans, and participants and beneficiaries of these plans during the COVID-19 National Emergency.
Extensions for Participants
- How much time a participant has to enroll in coverage under a group health pla
- How much time a participant has to elect COBRA continuation coverage
- The length of premium grace periods for COBRA continuation coverage
- The amount of time a participant has to submit claims for coverage and dispute denials of claims
- Special health plan enrollment period extensions
- How much time a participant has to notify a health plan of a qualifying event or disability
Extensions for Group Health Plan Sponsors or Administrators
- How much time a group health plan sponsor or administrator has to provide a COBRA election notice
All group health plans, disability and other employee welfare benefit plans, and employee pension benefit plans must disregard the period from March 1, 2020 until sixty (60) days after the announced end of the National Emergency or such other date announced in a future notification (the “Outbreak Period”) in calculating any time limit or notification deadline for the items addressed in the Notice.
For example, let’s assume that the National Emergency ends on July 31, 2020. In this case, the Outbreak Period ends September 29, 2020 – the 60th day after the end of the National Emergency.
Employee A is eligible for, but previously declined participation in, her employer-sponsored group health plan. On March 31, 2020, Employee A gave birth and would like to enroll herself and the child into her employer's plan; however, open enrollment does not begin until November 15. When may Employee A exercise her special enrollment rights?
Answer: the Outbreak Period is disregarded for purposes of determining Employee A’s special enrollment period. Employee A and her child qualify for special enrollment into her employer's plan as early as the date of the child's birth. Employee A may exercise her special enrollment rights for herself and her child into her employer's plan until 30 days after September 29, 2020, which is October 29, 2020, provided that she pays the premiums for the period of coverage back to the date of birth, when the coverage becomes active.
Priority Health will follow our standard policies for collecting and crediting monthly premiums. For retroactive enrollments, premium will be collected starting the effective date of coverage. To ensure premium invoicing is accurate, employers should term any COBRA enrollee who has failed to pay their premium within the allotted grace period. If, during the Outbreak Period, that enrollee brings their premium current, the employer will reinstate the enrollee’s COBRA coverage. Subsequent premium invoices will reflect the added premium cost for the months of coverage previously not billed.
For retroactive enrollments:
Our claims administration system will not accept or pend claims for participants that are not enrolled in coverage. Providers will receive a rejection indicating the member has no coverage, and will be required to resubmit claims once the participant is enrolled.
For retroactive terminations:
Priority Health may reprocess any claims that have been paid for dates of service after the member’s termination date. Members and providers will be notified if a medical claim has been reprocessed, indicating the member was not eligible for coverage on the date of service, and funds will be recouped from providers as appropriate. For pharmacy claims that are reprocessed, we will send notice to the member with the amount owned requesting payment within 30 days. We will follow up with phone calls, and if no response is received, we will send the member to collections.
No, Priority Health will not pend claims for COBRA enrollees. In order to limit potential financial risk to our employer groups and the health plan and prevent a large volume of retroactive terminations, we strongly recommend that all employers manage their COBRA enrollments on a month-to-month basis. iSolved will be providing our mutual customers with weekly reporting and information on their website to support this process; groups that use alternative COBRA administrators should inquire about what additional services are available during this time.
Once an employee’s active status has ended, a termination should be submitted to Priority Health. COBRA enrollments should be submitted once an employee has elected COBRA and paid their first month of premium. Terminations and reinstatements of COBRA coverage may be made on an ongoing basis during this time, based on the employee’s paid status.
Claims for participants covered under a self-funded Priority Health plan and a Priority Health stop loss policy affected by this Notice will be eligible for coverage. Customers with stop loss coverage through an outside carrier should consult with that carrier to confirm coverage.
Employers are responsible to pay their premium invoice as billed. For this reason, we encourage our customers to monitor their COBRA enrollments on a regular basis during this time. If an employer is concerned about their ability to pay their invoice, they should reach out to Priority Health Premium Management or their Account Manager for assistance in setting up a payment plan.
No, the Notice does not affect the standard length of COBRA coverage (18-month or 36-month) that a participant is eligible to receive.
Priority Health is partnering with iSolved to support our mutual customers. Employer groups utilizing iSolved as their COBRA administrator will receive letters from iSolved in the next week with information about how iSolved will handle COBRA notices and COBRA administration in compliance with the Department of Labor Notice, as well as additional resources and FAQs. Priority Health will be covering any costs associated with additional COBRA beneficiary notifications as part of our value added benefit to our group customers. Employer that contract directly with iSolved for additional administrative services, such as flex, should reach out to iSolved for information about any additional fees they may incur.
Spectrum Health Toolkit
This toolkit helps employers navigate their return to work plan, including an employer hotline, symptom checker, downloadable guide and more.