Frequently asked questions for agents
Last updated 04/05/2023
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.
On January 30th, 2023, the Biden administration announced the end of the COVID-19 Public Health Emergency. As a result, certain requirements around COVID testing and treatment have lifted. We have updated the FAQ below to reflect our current policies based on the new regulatory guidelines.
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 until supplies run out.
- At-home tests purchased from a pharmacy or retailer: There are several FDA approved COVID tests members can purchase from pharmacies or retailers. The list of approved tests can be found here. Over the counter tests are no longer covered under Priority Health plans, however, tests are generally considered to be an HSA/FSA qualified expense. FEHB members can still be reimbursed for OTC tests after May 11, 2023 by filling out this reimbursement form.
- Diagnostic tests ordered by a health care professional: Beginning May 12, 2023, medically necessary diagnostic covid testing will be covered as any other diagnostic testing. Members will be responsible for any applicable copays, coinsurance, deductibles, etc.
COVID-19 virtual care and treatment
Effective Jan. 1 2023, standard virtual coverage will reflect the below. Please refer to our telemedicine medical policy for move coverage information.
Self funded groups have the option to customize these benefits. Please refer to plan documents.
|Line of Business||2023 Virtual Care Service Coverage|
|Small Group - ACA||$10 copay before deductible||$10 copay after deductible|
|Large Group - ACA||$0 copay before deductible||$0 copay after deductible|
|Self-Funded (ASO)||Group specific||Group specific|
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. Members can also call the customer service number on the back of their member ID card.
During the PHE, certain HIPAA standards were relaxed related allow for more flexibility for virtual care. After the PHE ends, providers will again be subject to stricter privacy and security standards for virtual care.
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).
While the Federal Government will be covering the cost of the vaccine for each individual, 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. We will continue to update this as more information becomes available.
The estimated cost of an administration could vary from $17 – $40 dollars per dose. The administration of the vaccine is covered under a plan's preventive benefit. Preventive benefits are covered at in network providers. Priority Health's standard is to apply cost sharing for out of network preventive care. Check your plan documents to confirm.
DOL, IRS and Treasury Department Joint Notice
The Department of Labor's benefit extensions end 60 days after the end of the COVID Public Health Emergency (July 10th). This includes:
- 30-day period (or 60-day period in certain circumstances) to request special enrollment rights under HIPAA.
- 60-day COBRA election period, the timeframe for making initial and on-going timely COBRA premium payments and the date for individuals to notify the plan of a COBRA qualifying event or determination of disability.
- Deadlines for participants to file a benefit claim, to appeal a denied claim, and to request or perfect an external review of a denied claim.
- The required extensions to the claims filing deadlines also extends the run-out periods for health flexible spending arrangements (general and limited purpose).
- Mail order prescriptions continue to be available. Members should talk directly to their pharmacy to confirm if they will continue to offer local delivery.
Spectrum Health Toolkit
This toolkit helps employers navigate their return to work plan, including an employer hotline, symptom checker, downloadable guide and more.