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Thursday, May 21 -
Federal Agencies Allow
Significant Timeframe Extensions for Group Health Plans
On April 29, 2020, the DOL, Treasury Department, and IRS
issued a rule extending certain timeframes otherwise applicable to group health
In a news release, the DOL stated
that the rule “extends certain timeframes affecting participants’ rights to
healthcare coverage, portability, and continuation of group health plan
coverage under COBRA, and extends the time for plan participants to file or
perfect benefit claims or appeals of denied claims. These extensions provide
participants and beneficiaries of employee benefit plans additional time to
make important health coverage and other decisions affecting their benefits
during the coronavirus outbreak.”
The rule is applicable to group health plans subject to
ERISA and the Internal Revenue Code, and CMS has announced that it concurs with
the rules specified in the Notice and, on Friday May 15
similar guidance applicable to non-Federal governmental entities under
provisions in the Public Health Services Act.
Notably, the guidance issued by CMS makes these extensions voluntary for
non-Federal governmental entities but encourages their use.
When applying the rule, all group health plans must
disregard the period from March 1, 2020 until sixty days after the end of the
National Emergency (the ‘‘Outbreak Period’’) for all plan participants,
beneficiaries, qualified beneficiaries, or claimants in determining the
following periods and dates--
- HIPAA Special Enrollments. The 30-day timeframe in which employees can apply for coverage due to marriage, birth, adoption, placement for adoption, and loss of other coverage. Additionally, the 60-day timeframe that applies to changes in eligibility for state premium assistance under the Children’s Health Insurance Program is also extended.
- COBRA Election Period. The 60-day deadline for participants to elect COBRA.
- COBRA Notice of Qualifying Event. The 30- or 60-day deadline for employers or individuals to notify the plan of a qualifying event.
- COBRA Determination of Disability. The 60-day deadline for individuals to notify the plan of a determination of disability.
- COBRA Election Notices. The 14-day deadline for plan administrators to furnish COBRA election notices.
- COBRA Payment Deadlines. The 45-day initial premium payment deadline and the 30-day subsequent premium payment deadline.
- Claims Filing Deadlines. The deadline to file a claim for benefits under the group health plan. This includes health FSAs.
- Requests for an Appeal. The 180-day deadline to file an appeal of an adverse benefit determination.
- Requests for External Review. The 45-day day deadline to request an external review after a final internal adverse benefit determination.
- Filing information to perfect a claim. The date within which a claimant may file information to perfect a request for external review upon a finding that the request was not complete.
The following examples illustrate the timeframe for
extensions required by the rule.
assumed end date for the National Emergency is needed to make the examples
clear and understandable.
the examples assume that the National Emergency ended on April 30, 2020, which
makes the outbreak period the period from March 1, 2020 to June 29, 2020.
As a reminder, the outbreak period must be
disregarded when determining the deadlines outlined above.
Example 1 – COBRA Election
Billy terminated employment and his coverage ended on
February 8, 2020.
He received his COBRA
notice on the date of termination.
normal application of the COBRA rules, Billy would have until April 8 to elect
COBRA (60 days after he lost coverage).
Under application of the new rules, Billy’s deadline clock to
elect COBRA stopped ticking on March 1 and will not begin again until June 30
(the day after the end of the outbreak period).
In Billy’s example, 21 days of the 60-day election period had already
passed prior to commencement of the outbreak period. Since the outbreak period
must be disregarded, Billy will have 39 days left to elect coverage once the
outbreak period ends, which means his new deadline date is August 7, 2020.
Example 2 – Special Enrollment
Jodi is eligible for, but previously declined participation
in, her employer’s group health plan.
March 31, 2020, Jodi gave birth and would like to enroll herself and the child
into the plan.
Under normal application
of the rules, the plan allows for special enrollment for 30 days after birth.
Under application of the new rules, the outbreak period is
disregarded for purposes of determining Jodi’s special enrollment period.
Jodi may exercise her special enrollment
rights for herself and her child until 30 days after June 29, 2020, which makes
her new deadline for enrollment July 29, 2020, provided she pays the premiums
for any period of coverage.
since this is a birth, coverage will be retroactively effective to the date of
birth, even if it is not elected until July 29
Example 3 – Payment of Subsequent COBRA Premiums
As of March 1, 2020, Mary had previously elected and was
receiving COBRA coverage under a group health plan.
Premium payments are due on the first of the
The plan does not grant qualified
beneficiaries any longer than a 30-day grace period for making premium
Mary did not make the March
payment or any subsequent payments during the outbreak period.
As of July 1, Mary has made no premium
payments for March, April, May, or June.
Under application of the new rules, the outbreak period is
disregarded for purposes of determining whether monthly COBRA premium payments
This means that Mary’s new
deadline for making a timely payment for March, April, May, and June is July
29, 2020, and Mary is entitled to COBRA coverage during those months if she
timely makes payment by that date.
that Mary may not skip a month and request coverage only for June after missing
the March, April, and May payments.
Mary wants coverage in June, she must pay all that is owed for March, April,
and May, and June.
Tuesday, May 5 -
are plans first required to comply and for how long?
are required to cover items and services relating to COVID-19 diagnostic
testing that were furnished on and after March 18, 2020, and to continue to do
so through the end of the public health emergency. Unless extended or
terminated earlier, the public health emergency related to COVID-19 will end on
June 16, 2020.
types of testing must be covered?
guidance clarifies that in addition to tests that determine whether an
individual has the virus based on the presence of COVID-19 virus genetic
material in the body, a group health plan must also cover serological testing
to detect COVID-19 antibodies. All tests must be either: (1) authorized by the
Food and Drug Administration (FDA), (2) under review by the FDA, (3) developed
and authorized by a state, or (4) determined appropriate by the Secretary of
Health & Human Services.
items and services must be covered in full during a visit?
plans "must cover items and services furnished to an individual, during
visits that result in an order for, or administration of, a COVID-19 diagnostic
test." The FAQs clarify that if the attending provider determines that
other tests, such as influenza or blood tests, should be performed during a
visit to help determine whether COVID-19 diagnostic testing should be
conducted, "and the visit results in an order for, or administration of,
COVID-19 diagnostic testing," the plan must cover those services in full.
COVID-19 diagnostic testing is not ordered or administered as a result of the
visit, full coverage for these services is not required.
a plan impose any cost-sharing, prior authorization, or medical management
requirements for COVID-19 testing?
the requirement to cover COVID-19 diagnostic testing without cost-sharing apply
to out-of-network providers?
This requirement applies to out-of-network providers, including HMOs that
otherwise do not cover non-emergency out-of-network services. Out-of-network
providers would be reimbursed based on the cash price listed by the provider on
a public website or the amount negotiated by the plan with the provider.
what circumstances are services considered to be furnished during a visit?
FFCRA requires plans to cover COVID-19 diagnostic testing services during
office visits including in-person and telehealth visits, as well as urgent care
centers and emergency rooms. The guidance defines the term "visit"
broadly "to include both traditional and non-traditional care settings in
which a COVID-19 diagnostic test … is ordered or administered."
the guidance does not require group health plans to include a benefit with a
telehealth provider, any services offered by a provider through a telehealth
visit or other remote visit for COVID-19 diagnostic testing must be covered in
Friday, May 1 -
April 28, 2020, t
Department of Labor’s Employee Benefits Security Administration (EBSA) and the
IRS issued deadline relief and other guidance under ERISA to help employee
benefit plans, plan participants, employers, plan sponsors and fiduciaries, and
other service providers impacted by the coronavirus outbreak. HHS announced
that it will release similar guidance for non-federal governmental health
Below are the
details for group health plans as outlined by the Employee Benefits Institute
of America (EBIA) via Thomson Reuters:
- Deadline Extensions. The guidance
broadly extends numerous plan deadlines applicable to participants and
administrators, and the rule gives several examples. Specifically, the
“outbreak period” beginning March 1, 2020, and ending 60 days after the
announced end of the COVID-19 emergency is to be disregarded for the following
- COBRA. Multiple COBRA
deadlines have been extended until after the outbreak period ends, including
(1) the 30- or 60-day deadline for employers or individuals to notify the plan
of a qualifying event; (2) the 60-day deadline for individuals to notify the
plan of a determination of disability; (3) the 14-day deadline for plan
administrators to furnish COBRA election notices; (4) the 60-day deadline for
participants to elect COBRA; and (5) the 45-day deadline in which to make a
first premium payment and 30-day deadline for subsequent premium payments.
. The 30- and
60-day HIPAA special enrollment periods are extended. Thirty-day special
enrollment periods may be triggered when eligible employees or dependents lose
eligibility for other health plan coverage in which they were previously
enrolled, and when an eligible employee acquires a dependent through birth,
marriage, adoption, or placement for adoption. Sixty-day special enrollment
periods may be triggered by changes in eligibility for state premium assistance
under the Children’s Health Insurance Program.
. The deadlines are
extended for individuals to file claims for benefits, for initial disposition
of claims, and for providing claimants a reasonable opportunity to appeal adverse
benefit determinations under ERISA plans and non-grandfathered group health
group health plan deadlines have been extended for providing a state or federal
external review process following exhaustion of the plan’s internal appeals
procedures. (State deadlines may vary; plans using a federal external review
process must allow at least four months after the receipt of a notice of
adverse benefit determination in which to request an external review.) Other
deadlines that apply for perfecting an incomplete request for review are also
- Furnishing Notices. Plans and
responsible plan fiduciaries will not be treated as having violated ERISA if
they act in good faith and furnish any notices, disclosures, or documents that
would otherwise have to be furnished during the outbreak period (including
those requested in writing by a participant or beneficiary) “as soon as
administratively practicable under the circumstances.”
- Exchange Enrollment. The FAQs remind
participants who lose their employer-sponsored health coverage that they
qualify for a special enrollment period in which to enroll in an Exchange plan
outside of the Exchange’s annual open enrollment period within 60 days before
or after losing the coverage. Exchanges must also provide special enrollment
periods for loss of coverage due to a family member’s death or when an employer
stops contributing to COBRA. Individuals are also reminded that Exchange
coverage may be more affordable than COBRA.
- Forms 5500 and M-1. The notice
confirms that Form 5500 filing relief is provided in accordance with IRS
guidance, which provides that filings otherwise due on or after April 1 and
before July 15, 2020, are now due July 15, 2020. In addition, the notice provides
relief for Form M-1 filings for the same period of time. Form M-1 must be filed
by multiple employer welfare arrangements (MEWAs) and certain other entities to
report compliance with specified ERISA group health plan rules.
Along with the guidance, the EBSA issued Notice 2020-01 along with
FAQs to help
provide additional detail and explanation of the relief provisions.
Thursday, April 23 -
Dental emergencies can occur at any moment. With social distancing and dental office closures, many dentists are offering virtual visits to diagnose dental concerns such as abscesses or mouth pain. Don't wait – call your dentist today for more information.
Wednesday, April 22 -
Assistance Behavioral Health program provides a comprehensive clinical
assessment & referral process, on-site & online training,
short-term behavioral health coaching, and web-based services. The
outbreak of COVID-19 has temporarily shifted the norms of everyday life
and can be stressful. Fear and anxiety about any disease can be
overwhelming. Getting help to cope with stress will make you, the people
you care about, and your community stronger. Your employees can contact a
Behavioral Health Team designed to help during challenging times. Talk to
your Account Manager or Wellness Consultant today if you’d like to offer
this Gilsbar service to your employees.
Tuesday, April 21 -
In these rapidly
changing times, it can be difficult to know when a minor injury or illness
necessitates a visit to the urgent care or emergency room. When members
are not experiencing symptoms of novel coronavirus, it can benefit the
member, their family, and the healthcare professionals they would have
interacted with to lessen contact and reduce exposure by utilizing a
Telemedicine has been
advertised in the past as being a convenient option for members who may be
traveling or are unable to visit a provider in-person for any number of
reasons. However, this current crisis shows just how beneficial telemedicine
can be to keeping people healthy and flattening the curve. Using video chat or
a phone call, telemedicine allows a provider to gather information from an
individual to determine if additional care is needed, or if symptoms can
continue to be self-monitored at home. Prescriptions can also be sent directly
to member's local pharmacy if medically necessary.
On the Harvard Health Blog,
Dr. Lee H. Schwamm noted, "The number one job for all of us is to avoid
becoming a carrier and distributor of the virus. By using virtual care for much
regular, necessary medical care, and deferring elective procedures or annual
checkups, we free up medical staff and equipment needed for those who become
seriously ill from COVID-19. Additionally, by not congregating in small spaces
like waiting rooms, we thwart the ability of the virus to hop from one person
If you are interested in
learning more about telemedicine and Gilsbar's preferred telehealth provider,
MDLive, reach out to your account manager today.
Gilsbar's Commitment to
While Gilsbar is considered
an essential service and our office remains open, 96% of our workforce was
remote within 24 hours of our leadership making the decision on March 13 to
encourage social distancing. We are functioning at 100% and it is business as
usual. Our partnership with you is an important one and we are committed to
providing the same high level of service both you and your clients expect.
Wednesday, March 25 -
Gilsbar’s Case Management team is proactively reviewing claim reports to identify COVID-19 diagnoses for our members and their families. When identified, an assigned Case Manager calls to assist the member in any way they can. Gilsbar is working to help your members navigate the COVID-19 virus.
Thursday, March 19 -
On March 18, 2020, the Senate passed, and the President signed into law sweeping legislation in response to the COVID-19 pandemic. The Families First Coronavirus Response Act is designed to help American families prioritize health and safety during this national emergency.
The law requires testing for the COVID-19 virus and also expands FMLA and sick leave available to employees while providing tax credits to employers that provide the leave. Below are the details as outlined by the Employee Benefits Institute of America (EBIA) via Thomson Reuters:
Mandated Coverage. Group health plans and insurers offering group or individual health insurance must cover—without cost-sharing, preauthorization, or other medical management requirements—FDA-approved, in vitro diagnostic products to detect the virus that causes COVID-19. The coverage must include related services furnished during urgent care, emergency room, or in-person or telehealth provider visits that result in an order for or administration of a covered diagnostic test. This requirement, which cross-references HIPAA portability definitions and enforcement provisions, and also applies to grandfathered health plans, is effective from the date of enactment for the duration of the public health emergency declared by the Secretary of HHS.
FMLA Expansion. The legislation includes the Emergency Family and Medical Leave Expansion Act, which amends the FMLA to require employers with fewer than 500 employees to provide paid public health emergency leave to certain employees through December 31, 2020. The emergency leave generally is available when an employee who has been employed for at least 30 days is unable to work or telework due to a need for leave to care for a son or daughter under age 18 because a school or place of care has been closed, or a childcare provider is unavailable, due to an emergency with respect to COVID-19 that is declared by a federal, state, or local authority. The first 10 days of leave may be unpaid and then paid leave is required, calculated based on an amount not less than two-thirds of an employee’s regular rate of pay and the number of hours the employee would otherwise be normally scheduled to work, not to exceed $200 per day and $10,000 in the aggregate. Certain exemptions and special rules apply, and a tax credit may be available (see below). [EBIA Comment: No changes have been made to the FMLA’s health benefit provisions. But the additional leave rights may result in more employees taking FMLA leave, which will affect administration of group health plans. Employers should review their policies and procedures in light of the changes (e.g., new definitions and temporary timeframes).]
Emergency Paid Sick Time. Private employers with fewer than 500 employees, and public employers of any size, must provide 80 hours of paid sick time to full-time employees who are unable to work (or telework) for specified virus-related reasons. Part-time employees are entitled to sick time based on their average hours worked over a 2-week period. This amount is immediately available regardless of the employee’s length of employment. The maximum amounts payable vary based on the reason for absence. Employees who are (1) subject to a quarantine or isolation order, (2) advised by a health provider to self-quarantine, or (3) experiencing symptoms and seeking diagnosis, must be compensated at their regular rate, up to a maximum of $511 per day ($5,110 total). Employees caring for an individual described in category (1), (2), or (3), caring for a son or daughter whose school is closed or child care provider is unavailable, or experiencing a “substantially similar condition” specified by HHS must receive two-thirds of their regular rate, up to a maximum of $200 per day ($2,000 total). Employers cannot require employees to find a replacement worker or use other sick leave before this sick time. Employers may exclude health care providers and emergency responders, and the DOL can issue regulations exempting businesses with fewer than 50 employers. The sick leave mandate takes effect not later than 15 days after enactment and expires December 31, 2020.
Tax Credits. The legislation provides payroll tax credits for employers that make required sick or family and medical leave payments, as described above. The credit is increased for expenses the employer pays or incurs to provide and maintain a group health plan that are excludable from employees’ income as accident and health plan coverage and are “allocable” to these leave payments under rules to be prescribed by the Treasury Secretary. Various limitations apply—e.g., on the amount of wages and number of days taken into account—and the credit is not available to certain governmental employers.
Thursday, March 19 -
On March 18, 2020, the U.S. Senate voted to approve a coronavirus relief bill that was passed by the U.S. House of Representatives over the weekend. This bill requires employers to provide paid leave for some employees related to the coronavirus (COVID-19) pandemic, among other measures. As the industry seeks to interpret this new law, Gilsbar will keep you informed.
Thursday, March 12 -
Gilsbar’s Preparations for the Coronavirus
Gilsbar has been monitoring developments with COVID-19 (2019 Novel Coronavirus) since its inception. When responding to an infectious disease, our company closely follows the recommendations and guidance made by the Centers for Disease Control and Prevention as well as state and county health departments. While many variables are surrounding COVID-19, we are committed to providing quality service to you, our valued partners. Here at Gilsbar, it is business as usual. Our top priorities are ensuring the well-being of our employees and maintaining our ability to serve our clients.
What is Gilsbar Doing?
Our employees are taking the necessary steps to prepare for the potential spread of Coronavirus. Prevention is a priority. Here are some of the steps we are taking to ensure a safe work environment and maintain our operations:
Remote Work: For years, Gilsbar has worked with a flex work program that allows our employees to successfully meet the needs of our partners and clients anywhere while maintaining a better work/life balance. Gilsbar is fully capable to serve our clients remotely, if necessary. We are confident that there will be no disruption to our operations.
Communication: Gilsbar employees have the ability to connect online with a comprehensive digital platform. With virtual meetings and online communication, we will continue to serve our clients with our customary high-level of service.
Sanitation: Facilities are cleaned daily and additional focus has been placed on wiping down all high-touch surfaces.
Education: Employees are being educated on how to prevent the virus from spreading.
Our top priorities are the safety and health of our employees and meeting the needs of our partners and clients. Gilsbar will continue to monitor this evolving situation. If you have any questions, please do not hesitate to contact your contact at Gilsbar.