Self-Funded Plans: Announce Coverage for COVID-19 Testing with a Summary of Material Modification

All group health plans are subject to the national mandate to provide coverage for COVID-19 testing with no out-of-pocket cost to the participant (other than retiree-only plans or HIPAA excepted benefit plans). This mandate includes any related provider charge.

For insured plans, the insurance vendor is responsible for amending the policy/plan and notifying participants.

For self-insured plans, the plan sponsor (employer) is generally responsible for amending the plan and notifying participants. Of course, coordination with your administrative services provider is a first step to ensure this coverage is being afforded.  Then, you will want to let employees know as quickly as possible that this coverage is available. When you do, make that communication really work for you by drafting it as a Summary of Material Modification.

Sample Summary of Material Modification

Here’s how it would read:

Summary of Material Modification to the (insert name of plan)

Effective Date: March 18, 2020

In keeping with the Families First Coronavirus Response Act, the Plan has been amended to cover COVID-19 Testing. Benefits include:

  • In vitro diagnostic testing (e.g., nasal swab)
  • Items and services related to office visit, telehealth session, urgent care visit, or emergency room visit for COVID-19 diagnostics that result in an order for or administration of a COVID-19 test (but only to the extent such items and services relate to the furnishing or administration of the test or to the evaluation of whether the test is needed).

These benefits are provided with no cost-sharing. There is no deductible, copay or coinsurance for these items and services.

Suggested Cover Letter/Email

(Regulations require you to briefly describe the SMM and state its importance.)

Our benefit plan has been amended to include COVID-19 testing with no cost-sharing. The attached Summary of Material Modification describes those benefits. We do not know at this time whether a physician must refer you for a test, but a referral is recommended.

You should review this information carefully and share it with your covered dependents. Keep this information with your Summary Plan Description  for future reference. In the event of a conflict between the official Plan Document and this SMM, the SPD, or any other communication related to the Plan, the official Plan Document will govern.

How To Distribute the SMM

Plans already using electronic distribution under the DOL’s rules may continue to do so. Unless COBRA participants have consented to electronic distribution, you’ll have to mail the SMM to them.  If you are not currently using electronic distribution, you will have to mail the SMM.  If you maintain a benefits website, remember to post the SMM to that site as well.

About the Author

Sue Thomas

Posted in: Employee Benefits, Human Resources

Posted by Sue Thomas

Director, Contracts & Compliance. Sue has more than 30 years of intensive, hands-on experience working with a wide variety of employee benefit plans. As the Director of Contracts and Compliance, Sue is responsible for the management of all BSG® client contracts, including insured contracts, service contracts, and self-insured contracts as well as ensuring that these materials comply with all applicable state and federal benefit regulations. A graduate of the University of Wisconsin-Milwaukee, Sue has completed the RHU program, six CEBS courses and holds a Life and Health agent license.