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Frequently Asked Questions for Employer Groups

All Wellmark members, as well as members of self-funded plans, have no cost-share for appropriate testing and related services to diagnose or detect COVID-19. This is required by the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act and remains in place as long as we are in a public health emergency, as declared by the federal government.

Fully-insured and Medicare supplement members also had no cost-share for in-patient treatment of COVID-19 when seeking care from an in-network provider through June 30, 2021. Wellmark will work with self-funded groups that have implemented similar benefits for their members and/or wish to extend the benefit beyond June 30, 2021.

Effective January 15, 2022, members of Wellmark health plans (excluding/including Medicare Supplement members) will be eligible for at-home over-the-counter (OTC) COVID-19 test coverage and reimbursement with no member cost-share, subject to certain limitations:

  • To be covered/reimbursed, the OTC COVID-19 test must be purchased on or after January 15, 2022. Wellmark will not be reimbursing OTC COVID-19 tests purchased before that date.
  • The OTC COVID-19 test must be approved by or have an emergency use authorization from the FDA. Visit the FDA's website External Link to make sure the test you are planning to purchase qualifies for coverage. Enter "OTC" in the search box near the middle of the page to see the list of tests that qualify.
  • The OTC COVID-19 test must be one for which you collect your own specimen and read the test at home. OTC COVID-19 tests that require you to drop off or mail your specimen to a laboratory are not covered under the OTC COVID-19 test coverage.
  • Members will only be reimbursed for up to eight OTC COVID-19 tests per member (including dependents on the same health plan) in a month. As an example, if a family has five members on the same health plan, the family is eligible to be reimbursed for up to 40 OTC COVID-19 tests each month.
  • OTC COVID-19 tests must be purchased from the pharmacy counter of an in-network pharmacy to receive direct coverage. If purchased from any retailer at a regular check-out, you will need to pay retail price and submit a claim to CVS Caremark for reimbursement.
  • OTC COVID-19 tests covered by your health plan are for the personal use of the member requesting reimbursement from the health plan and their dependents on the same health plan. These tests should only be used by that member and their dependents.
  • Your health plan does not cover return to work/return to school/return to other activity or travel eligibility testing.

For fully-insured groups:

Wellmark will reimburse fully-insured members for FDA approved OTC COVID-19 tests that are purchased on or after January 15, 2022. Wellmark will not be reimbursing OTC COVID-19 tests purchased before that date. Fully-insured members will only be reimbursed for up to 8 OTC COVID-19 tests per member (including dependents on the health plan) in a calendar month. Visit Wellmark.com/Coronavirus to learn how to submit a claim for OTC COVID-19 tests. Keep in mind, this is still relatively new and some pharmacies may not be ready to process point-of-sale claims.

This is a rapidly evolving situation, but Wellmark will provide additional updates as new information is available. If you have any questions about Wellmark's plan to implement the guidance released earlier this week, please contact your Wellmark account team.

For self-funded groups:

Pharmacies play a very large role in the access and sale of these OTC COVID-19 tests. For that reason (and because OTC COVID-19 tests are generally not available for purchase through traditional medical providers), Wellmark has partnered with CVS Caremark, its pharmacy benefits manager, to provide members with a streamlined purchase experience where members will not have to pay anything upfront for the OTC COVID-19 test if they purchase the test from the pharmacy counter of an in-network pharmacy. Self-funded health plans that utilize Wellmark/CVS Caremark as its pharmacy benefits manager will be billed directly through normal CVS Caremark billing processes for the OTC COVID-19 tests. Keep in mind, this is still relatively new and some pharmacies may not be ready to process point-of-sale claims.

Starting Jan. 15, 2022, those members will be able to get tests in person at most pharmacies, as well as order them online through national retail pharmacy chains like CVS and Walgreens, without upfront payment. Members will be able to find in-network pharmacies by visiting this site External Link.

Members who purchase OTC COVID-19 tests from out-of-network pharmacies or from non-pharmacy retailers are still eligible for reimbursement. However, Wellmark strongly recommends that members of self-funded health plans that have pharmacy benefits with Wellmark/CVS obtain OTC COVID-19 tests from an in-network pharmacy, as the member will pay nothing out-of-pocket. OTC COVID-19 tests must be purchased from the pharmacy counter to be covered with no out-of-pocket costs. Members purchasing the test at a regular checkout will need to pay for that test at the retail price and submit a claim to CVS Caremark for reimbursement. If the member does decide to go to an out-of-network pharmacy or a non-network retailer, the member's reimbursement may be limited to $12 per test (or $24 for a box of two tests). Visit Wellmark.com/Coronavirus to learn how to submit a claim for OTC COVID-19 tests.

For self-funded health plans that carve out their pharmacy benefits to an external pharmacy benefits manager, Wellmark strongly recommends that such health plans accept and pay claims for OTC COVID-19 tests through the pharmacy benefit or the medical benefit, but not both. Reimbursing through both benefit channels can lead to increased member fraud, waste and abuse (for example, difficulties in identifying when a member has submitted to both benefits for reimbursement and may get double paid), as well as difficulties in tracking OTC COVID-19 test reimbursement for purposes of implementing limits on the number of tests paid. In addition, if claims are processed through the medical benefit, Wellmark cannot offer price protection under the safe harbor. Our standard process will be that OTC COVID-19 test claims will be submitted to your PBM and claims submitted by the member to Wellmark will be denied with direction to submit the claims through the member's pharmacy benefit. Please communicate with your account team if there are concerns.

This is a rapidly evolving situation, but Wellmark will provide additional updates as new information is available. If you have any questions about Wellmark's plan to implement the guidance released earlier this week, please contact your Wellmark account team.

Effective Mar. 16, 2020 through Aug. 31, 2020, all Wellmark members had access to virtual health care visits with no cost-share. Standard benefits for such visits, including those for mental health reasons, resumed effective Sept. 1, 2020.

To avoid the spread of COVID-19, we encourage our members to take advantage of virtual visits with their current primary care physician, if they have this capability. For those who don't currently have a primary care physician, please use an in-network provider.

Covered Wellmark members may request an early refill through the pharmacy. The pharmacy has their own process to call the CVS help desk if there are issues. If a member continues to have issues, the member should call Customer Service.

No. Wellmark will not require customers to notify Wellmark in writing of a layoff or reduction of workforce hours through the end of the month in which the federal COVID-19 public health emergency declaration is allowed to expire.

Fully-insured groups

Yes. Wellmark's requirement for employees to be actively working in order to be eligible for coverage will be relaxed through the end of the month in which the federal COVID-19 public health emergency declaration is allowed to expire. Payment of premium is required to continue coverage for laid-off employees who are not actively at work and employees actively working.

Coverage must be offered on a uniform, non-discriminatory basis to all employees and employee premium contributions must be the same or less prior to the layoffs.

Self-funded groups

Yes. Payment of administrative fees, claims cost and stop loss premium is required to continue coverage for laid-off employees who are not actively at work. Coverage must be offered on a uniform, non-discriminatory basis to all employees and employee premium contributions must be the same or less prior to the layoffs.

For employers who have stop loss coverage through Wellmark - if their stop loss eligibility is impacted by COVID-19 due to a reduction in workforce until Wellmark communicates otherwise, the employer can still be covered under the stop loss policy during the current Policy Year as long as the PCPM premium for laid-off employees who are not actively at work and employees actively working continues to be paid as outlined within the eligibility guidelines and exceptions above. We will not require that an amended plan document permitting such continued coverage be sent to us for approval. However, in order to process claims accurately, we need to be made aware of any such plan changes as soon as possible.

If Wellmark is not a customer's stop loss carrier, Wellmark recommends that the customer verify this coverage with its stop loss carrier.

Fully-insured groups

Yes. Wellmark's requirement for employees to be actively working in order to be eligible for coverage will be relaxed through the end of the month in which the federal COVID-19 public health emergency declaration is allowed to expire. Payment of premium is required to continue coverage for laid-off employees who are not actively at work and employees actively working. This date will continue to be evaluated through the COVID-19 pandemic.

Coverage must be offered on a uniform, non-discriminatory basis to all employees and employee premium contributions must be the same or less prior to the layoffs.

Self-funded groups

Yes. Payment of administrative fees, claims cost and stop loss premium is required to continue coverage for laid-off employees who are not actively at work. Coverage must be offered on a uniform, non-discriminatory basis to all employees and employee premium contributions must be the same or less prior to the layoffs.

For employers who have stop loss coverage through Wellmark - if their stop loss eligibility is impacted by COVID-19 due to a reduction in workforce through the end of the month in which the federal COVID-19 public health emergency declaration is allowed to expire, the employer can still be covered under the stop loss policy during the current Policy Year as long as the PCPM premium for laid-off employees who are not actively at work and employees actively working continues to be paid as outlined within the eligibility guidelines and exceptions above. We will not require that an amended plan document permitting such continued coverage be sent to us for approval. However, in order to process claims accurately, we need to be made aware of any such plan changes as soon as possible. The timeframe for this will continue to be evaluated through the COVID-19 pandemic.

If Wellmark is not a customer's stop loss carrier, Wellmark recommends that the customer verify this coverage with its stop loss carrier.

Fully-insured groups

If one person remains actively employed, employees who have been laid off may elect to continue coverage at their expense under state continuation requirements by following the normal notice and election procedures. [Iowa Code Chapter 509B; South Dakota – SDCL 58-18-7.5 – 7.14]

If there are no active employees, the plan is terminated:

  • In Iowa, state continuation is not an option.
  • In South Dakota, state continuation may be available at the employee's expense for up to 12 months. [SDCL 58-18C-1]

Fully-insured and self-funded groups

For employers with 20 or more employees, if one person remains actively employed, employees may elect COBRA at their expense by following the normal notice and elections procedures.

If there are no active employees, the plan is terminated and COBRA is not an option.

Groups with Wellmark stop loss coverage

For employers who purchase Wellmark stop loss, standard contract provisions apply.

Fully-insured and self-funded groups

The employee may be reinstated the first of the month following the re-hire date without fulfilling an eligibility waiting period through the end of the month in which the federal COVID-19 public health emergency declaration is allowed to expire. The timeframe for this will continue to be evaluated through the COVID-19 pandemic.

For employers who have Stop-Loss coverage through Wellmark - if their employee stop-loss eligibility is impacted by COVID-19 due to a reduction in workforce, through the end of the month in which the federal COVID-19 public health emergency declaration is allowed to expire, laid off employees may be reinstated without fulfilling an eligibility waiting period. We will not require that an amended plan document permitting such rehire eligibility be sent to us for approval. However, in order to process claims accurately, we need to be made aware of any such plan changes as soon as possible. The timeframe for this will continue to be evaluated through the COVID-19 pandemic.

If Wellmark is not a customer's stop loss carrier, Wellmark recommends that the customer verify coverage with its stop loss carrier.

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