With Coronavirus COVID-19 creating so much uncertainty for so many businesses across the country, we decided to create a resource that answers the most frequently asked questions we’re receiving from our member groups.
The information below is divided into three categories: Employee Eligibility, Premiums and Administrative, and Employee Coverage. We’ll continue to update this resource as needed in accordance with how the situation develops.
Q: Will Total Health Care USA waive the new hire waiting period for employees returning from layoffs?
A: While Total Health Care USA 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, Total Health Care USA 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. (3/26)
Q: If an employee loses coverage due to layoff and then returns to work with a lapse in coverage but during same plan year, do accumulators reset?
A: No, accumulators will remain with the member under the same plan for the remainder of the plan year. (3/26)
Q: If employers need to temporarily lay off or reduce hours below full-time status for employees due to COVID-19 circumstances, can they continue to provide health benefits during this period?
A: Yes, employers can continue to provide benefits and should keep the employees status as “active” if employers choose to do so. This “active” status is effective March 12, 2020 through June 30, 2020. Reminder: an employer must be consistent with the options they offer to all similarly situated employees. (4/13)
Q: Is there a requirement to alter any plan documents as a result of the COVID-19 emergency mandates?
A: Due to the state of emergency, we are not requiring any changes to your plan documents at this time. We will continue to evaluate this as the situation evolves. (3/26)
Q: Is Total Health Care USA considering extending the dependent stop age of 26?
A: Total Health Care USA will not be changing our current policies regarding dependents aging off a group plan. For those dependents in need of ongoing coverage, they can purchase an individual plan or see if they qualify for a Healthy Michigan plan. (3/26)
Q: What if an employer needs to add or remove employees and/or dependents due to qualifying life events or make plan changes, but is not able to do so within the 30-day time frame due to COVID-19 circumstances?
A: Total Health Care USA will extend the 30-day time frame through April 30, 2020. (3/26)
Q: If an employee is still in their new hire waiting period and is laid off, will they be eligible to begin coverage once the waiting period is met?
A: Yes, if an employee is laid off before they meet the requirement for 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. (3/30)
Q: Will Total Health Care USA be holding a special enrollment period during this time?
A: Total Health Care USA is not opening up our commercial book of business for a special open enrollment at this time. Employers may still add employees or change coverage at qualifying events, including loss of other coverage. If you are unsure what constitutes a qualifying event, or if you have extenuating circumstances for an employee, please reach out to your Total Health Care USA Account Manager or Account Executive for assistance. (3/30)
Q: Is an employer allowed to subsidize premiums for employees enrolled in COBRA continuation coverage?
A: 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. (4/8)
Q: If an employee is laid off while still in their new hire waiting period, and not yet enrolled on the health plan, can that employee be offered COBRA?
A: 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 layoff occurred, they are not eligible for COBRA. (4/8)
Q: If an employee is laid off from work and collects unemployment benefits, are they still eligible to receive employer-sponsored health coverage?
A: Collecting unemployment does not affect the employer’s ability to offer health benefits during this time. (4/8)
Q: If employers can no longer provide health coverage to their employees, what options do employees have?
A: There are multiple options for employees based on their specific circumstances, including:
- COBRA – Employees will need to work with their HR department to verify eligibility.
- Individual Insurance – Employees may go online at THCmi.com and enroll directly with Total Health Care USA. We have a variety of plans with great benefits and affordable premiums. If individuals qualify for a tax credit, they can find Total Health Care USA plans on HealthCare.gov or by calling the Marketplace at 800.318.2596.
- Healthy Michigan Plan – Employees can visit mibridges.michigan.gov or contact their local Department of Human Services office, who can help verify their eligibility. They can call Michigan Enrolls at 888.367.6557 (TTY users call 711) and ask to get their coverage through Total Health Care. If they don’t select a carrier, one will be auto-assigned.
We have a team of individuals who will reach out to group members who lose their coverage due to COVID-19 to assist them in finding a new Total Health Care USA policy. (4/8)
Q: If an employer terminates an employee’s health plan due to the executive order, how soon can they purchase an individual healthcare plan through the Marketplace?
A: This would be treated as a Special Enrollment (SEP) for loss of coverage. We’re waiving the requirement for documentation due to loss of health coverage because of the COVID-19 crisis if individuals enroll directly through Total Health Care USA. Documentation is still required if they choose to enroll through the HealthCare.gov Marketplace.
Individuals enrolling through HealthCare.gov must choose the first of the month as their effective date. Dates must be within their 60-day window from the date they loss coverage. For example, if they lose coverage on 3/23, their effective date options would be 4/1 or 5/1.
Individuals enrolling directly in a health plan through Total Health Care USA can select the next day for coverage to ensure they do not have a coverage gap, or they can select the first of the following month. For example, if they lose coverage on 3/23, their effective date options are 3/24 or 4/1. (4/8)
Q: If an employee loses coverage should they be advised to use COBRA or enroll in an individual health plan through the HealthCare.gov Marketplace?
A: 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 a Special Enrollment (SEP) because the enrollee would be deemed ‘newly eligible for assistance’. The effective dates are applied as outlined above.
Additionally, 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 Total Health Care USA. (4/8)
PREMIUMS AND ADMINISTRATIVE
Q: Will Total Health Care USA adjust premium rates mid-year for groups that experience a significant fluctuation in enrollment?
A: No, Total Health Care USA will not be making mid-year rating adjustments due to changes in enrollment at this time. (3/26)
Q: Should employers experiencing changes in membership adjust their premium payments accordingly?
A: No, enrollment changes will continue to be reflected in the next billing cycle. (3/26)
Q: What is the standard employer premium payment grace period? Has that changed?
A: Our current grace period is 30 days from the due date. Keep in mind, your payment is for the following month, so if you are current with your payment, you’ll be paid through April. (3/26)
Q: Is Total Health Care USA extending grace periods for employers as they seek funding and reimbursement from announced government programs?
A: We’ll work closely with our agent and employer partners to determine the best course of action for their situation. (3/26)
Q: Will there be any delays in Total Health Care USA operations due to COVID-19 (claims paid, enrollment process, customer service staffing, invoices paid, etc.)?
A: We don’t anticipate any delays or disruption in our day-to-day operations as we have business continuity plans in place, including remote and virtual work processes. Many operations are done online already. Additionally, we have open enrollment materials available digitally. (3/26)
Q: Could an employer shift up to 100% of the premium liability to their employees (temporarily) in order to reduce operating costs and continue offering benefits?
A: While an employer 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. (3/30)
Q: If a large employer temporarily reduces their workforce related to COVID-19, how will that affect their applicable large employer status?
A: An employer’s status as an applicable large employer 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. (3/30)
Q: What information is Total Health Care USA able to provide employer groups that are applying for the Paycheck Protection Program loans made available through the CARES Act?
A: Employers may need to provide information on health care premiums for up to 24 months. Some individual lenders may request copies of invoices. A report supplying this information will be provided upon request. Copies of invoices are available if required by the lender. Please email your group name, group number, and the time period for reporting to email@example.com. (4/8)
Q: There has been some interpretation of the CARES Act suggesting that employers will need to update their plan documents reflecting coverage for COVID-19 testing and treatment and provide a Summary of Material Modification (SMM) to their employees. Will Total Health Care USA be updating SBCs to reflect this coverage?
A: Total Health Care USA’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. (4/8)
Q: Will Total Health Care USA be waiving NSF (Non-Sufficient Funds) Fees?
A: Total Health Care USA will be waiving NSF Fees for employer groups from March 12, 2020 through April 30, 2020. Employer groups must contact Total Health Care USA to set up a payment plan prior to becoming delinquent in their payments. (4/13)
Q: Will Total Health Care USA allow groups to request mid-year benefit changes in order to offer a leaner plan and reduce benefits costs?
A: Typically, Total Health Care USA does not allow mid-year plan changes. Groups considering a mid-year change should consult with their benefits attorney regarding ACA and ERISA considerations. If you are concerned about your ability to continue offering your current benefit plan to your employees, please work with your account manager to discuss available payment options and ways Total Health Care USA can work with your business. (4/21)
Q: What if a Total Health Care USA member is asked to pay out-of-pocket for a service that Total Health Care USA is covering in full related to COVID-19?
A: Members can follow the same process as they do today for claim reimbursement, utilizing our existing process. Claims are based on codes submitted, so no new process or indication will be needed. (3/26)
Q: Will the cost of COVID-19 testing and services associated with COVID-19 testing be covered at both in-network and out-of-network providers?
A: Yes, COVID-19 testing and all costs associated with COVID-19 testing will be covered in full for members, with no cost share, regardless of network status. (3/26)
Q: Does Total Health Care USA have COVID-19 test kits to send to members?
A: No, Total Health Care USA does not have access to COVID-19 test kits as we are not a health care provider. (3/26)
Q: What services are covered in full related to testing for COVID-19 and for which members?
A: For all commercial group members, 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. (3/26)
Q: How is Total Health Care USA covering the COVID-19 test for HSA-qualified High Deductible Health Plans (HDHP)?
A: HDHP members are covered in full, before deductible. As part of the Families First Coronavirus Response Act, members are 100% covered with no member cost share for COVID-19 diagnostic test and the administration of the test. (3/26)
Q: How is Total Health Care USA covering virtual visits during this time?
A: Starting March 1, 2020 through June 30, 2020, virtual care related to COVID-19 diagnostic testing and the administration of the test is 100% covered for all members, including HSA members, with no cost-sharing applied.
For all other virtual care, regular copays, deductibles, and coinsurance required by a member’s benefit plan applies. (4/28)
Q: Can Total Health Care USA members get prescriptions delivered to their home?
A: Yes, Total Health Care USA has partnered with CVS, Walgreens, Walmart, Costco, Meijer, Binson’s, and EnvisionMail for free home delivery of prescriptions for all Total Health Care USA plans. For details about delivery from these pharmacy partners, click the links listed below:
Binson’s Pharmacy: https://www.binsonsrx.com/service/free-home-delivery/
Q: Will Total Health Care USA members in Michigan be able to receive care from providers that come from other states to assist our hospitals and health systems during this crisis?
A: Governor Whitmer has issued an Executive Order that allows any provider licensed in any state to help with the COVID-19 crisis in Michigan without needing to be licensed by the State of Michigan. The Executive Order states, in part: “Any and all provisions in Article 15 of the Public Health Code are temporarily suspended, in whole or part, to the extent necessary to allow health care professionals licensed and in good standing in any state or territory in the United States to practice in Michigan without criminal, civil, or administrative penalty related to lack of licensure. A license that has been suspended or revoked is not considered a license in good standing, and a licensee with pending disciplinary action is not considered to have a license in good standing. Any license that is subject to a limitation in another state is subject to the same limitation in this state.” (4/8)
Q: How is Total Health Care USA responding to Executive Order 2020-25, allowing pharmacies to dispense emergency refills of non-controlled maintenance medications up to a 60-day supply?
A: Total Health Care USA 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. (4/8)
Q: How will Total Health Care USA cover inpatient and outpatient medical claims related to COVID-19 treatment?
A: Starting March 1, 2020 through June 30, 2020, Total Health Care USA will be covering the full cost of the treatment for COVID-19 when provided by an in-network provider.
Cost-sharing, including copays, deductibles, and coinsurance, will apply to the treatment of COVID-19 when provided by an out-of-network provider. (4/28)
Q: Will members receive credit for cost-sharing amounts paid by Total Health Care USA, such as copays for virtual care or deductible and coinsurance amounts for outpatient and inpatient treatment?
A: No, amounts paid by Total Health Care USA will not accumulate toward the member deductible, coinsurance maximum, or maximum out of pocket accumulators. (4/21)
Q: If outpatient or inpatient COVID-19 treatment services are rendered by an out-of-network hospital or provider, will the out-of-network out-of-pocket costs apply to the member? What about overflow facilities or field hospitals?
A: Cost-sharing, including copays, deductibles, and coinsurance, will apply to the treatment of COVID-19 when provided by an out-of-network provider.
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. Total Health Care USA will work with our provider partners throughout the state to ensure that members are not balance billed due to receiving care by an out-of-network provider during this time. (4/28)
Q: How will claims related to treatment of COVID-19 be identified? What types of claims are expected?
A: 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. Total Health Care USA 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. (4/21)
Q: Total Health Care USA has announced coverage in full at in-network providers for COVID-19 treatment through June 30, 2020. What will happen if a member starts treatment before that date, but remains hospitalized into July or requires additional follow up care in an outpatient setting?
A: Claims for observation or inpatient care will be paid based on the admission date. Total Health Care USA will continue to monitor this rapidly changing situation and make determinations for coverage with dates of service beginning after June 30, 2020 as we approach that date. (4/28)
Q: Will Total Health Care USA provide another extension of the temporary eligibility or claims payment provisions past June 30, 2020? What if a group wants to extend eligibility or coverage past that date?
A: Total Health Care USA will continue to monitor the situation as it evolves and make adjustments as needed to support our members and employer groups. Our temporary provisions do not extend past June 30, 2020 at this time. If an employer group chooses to make a permanent change to their plan, they should work with their account manager to do so. (4/21)