Members of fully-insured commercial plans, fully-insured group Medicare Supplement plans, and self-insured commercial plans that do not carve out pharmacy, will have the option of purchasing tests and submitting a claim for reimbursement to Harvard Pilgrim Healthcare, or obtaining a test through their pharmacy benefit without upfront cost at certain OptumRx-affiliated pharmacies. Visit COVID-19 Testing & Coverage for more information.
For tests obtained at the pharmacy, members should present their ID card at the pharmacy counter.
Note: Self-insured employer groups who carve out pharmacy coverage to a third party may choose to administer this benefit exclusively through their pharmacy benefit manager (PBM). Members of self-insured groups should follow up with their employer to confirm their coverage options.
Yes. Self-insured groups who have chosen to carve out pharmacy to a third party may have their PBM administer the at-home test benefit. Members of self-insured groups should follow up with their employer to confirm their coverage options.
Coverage is available through our pharmacy network without upfront costs to members. We are evaluating the possibility of establishing a more comprehensive direct coverage program.
We will make our best efforts to process member reimbursements within 30 days of receipt – assuming their reimbursement forms and receipts are complete.
We are in the process of determining how to create a bi-directional feed to ensure the allowed number of tests per month is not exceeded regardless of how the tests were covered (via the pharmacy or through the member reimbursement process).
COVID- 19 test-reporting capabilities are being assessed at this time.
If so, have you started any discussions with pharmacies, stores, and retailers to be able to create the preferred network?
Can you provide an overview of how this process will work and how this setup will be structured from an administrative perspective?
Coverage is available through certain pharmacies in our pharmacy network without upfront costs to members. We are evaluating the possibility of establishing a more comprehensive direct coverage program. Please visit COVID-19 Testing & Coverage for more information.
Yes. These claims will be processed for member reimbursement through the medical benefit. Tests purchased through resellers (e.g., eBay, Facebook Marketplace, etc.) are not eligible for reimbursement.
Members who purchase and pay out-of-pocket for at-home tests will be asked to follow the member reimbursement process detailed in the COVID-19 At-home Test Member Reimbursement Form. We will make best efforts to process reimbursements within 30 days of receipt.
The limit will be based on calendar month.
Note: In the event a member obtains less than eight tests in a given calendar month, they do not roll over into the next month (e.g., if a member receives six tests in January, they are not able to receive 10 tests in February).
No. At this time there is not a $12 cap on tests obtained outside of the preferred network.
No. Members will be reimbursed for tests purchased on or after January 15, 2022.
No. ASO accounts are subject to the FFCRA and CARES Act requirements.
We are not assessing a fee for processing the member reimbursements. We will reimburse members the cost of the tests minus tax and shipping.
If we develop a direct coverage method that meets the federal statutory criteria that includes both a pharmacy network and a direct-to-consumer shipping program, reimbursement may be capped at $12 per test for tests obtained outside of the preferred network.
No, tests purchased through a reseller (i.e., the employer group) are not eligible for reimbursement.
Worksite health and safety resources
General and industry-specific guidance to help prevent and reduce the spread of COVID-19.
No, members will not have to pay cost sharing for the emergency use authorization (EUA) COVID-19 vaccines.
Note: The Pfizer COVID-19 vaccine received full FDA approval on August 23, 2021.
The COVID-19 vaccine is available at mass vaccination sites and select retail pharmacies. It may also be available through certain hospitals, medical practices and local boards of health. Visit www.vaccinefinder.org or check your state government’s website to find out where the COVID-19 vaccine is available in your area:
The federal government is paying for the vaccine itself, and insurers are covering the cost of vaccine administration.
Coverage of COVID-19 treatment and testing
Harvard Pilgrim has been waiving member cost sharing (deductibles, copays and coinsurance) for COVID-19 treatment from in-network providers and for emergency services related to COVID-19 treatment from out-of-network providers.
Starting August 7, 2021, cost sharing for COVID-19 treatment will resume for Harvard Pilgrim policies purchased in Connecticut, Maine or New Hampshire. Cost sharing for COVID-19 treatment will continue to be waived for policies purchased in Massachusetts, per state regulation.
Members are covered without cost sharing for in-person COVID-19 testing, including antibody testing, until further notice.
Consistent with federal and state guidance, these tests will only be covered or reimbursed if they are medically necessary, as determined by a health care provider, in accordance with current CDC and state public health department guidelines. In-person COVID-19 tests that are not ordered or referred by a provider are not covered benefits. Testing will not be covered solely for general workplace health and safety, public health surveillance, or other purposes not primarily intended for a member’s individual COVID-19 diagnosis or treatment, except for Maine members when in compliance with and required by the state of Maine regulatory guidelines.
We will update this information as new guidance is issued.
Members should always use participating providers/laboratories for all in-person COVID-19 testing.
At-home COVID-19 PCR (polymerase chain reaction) tests are covered with orders or referrals from a physician or attending provider. At-home PCR tests that members order themselves, including through an online self-completed questionnaire, are not covered for reimbursement.
COBRA premium assistance (American Rescue Plan Act)
This information reflects Harvard Pilgrim Health Care’s interpretation of relevant statutes and guidance as of October 12, 2021. It is subject to change as further guidance is issued. This does not constitute legal advice. Employers, brokers and consultants should consult with their own legal counsel.
Under ARPA, “Assistance Eligible Individuals” (defined in a later FAQ), are eligible for COBRA premium assistance from April 1, 2021, through September 30, 2021.
It is the employer’s responsibility to determine eligibility and notify beneficiaries who may be eligible for ARPA premium assistance under COBRA or state continuation of coverage (mini-COBRA). The Department of Labor (DOL) has issued guidance on operation of COBRA premium subsidies and model notices.
For state continuation of coverage (mini-COBRA), it is the employer’s responsibility to provide notice to Harvard Pilgrim, identifying those beneficiaries who are eligible for ARPA premium assistance and have elected state continuation of coverage (mini-COBRA).
For premium payment and tax credit responsibilities, see below.
If the group health plan is subject to federal COBRA (i.e., the employer maintaining the plan employed 20 or more employees in the prior year), coverage would be managed by the employer group. The employer would pay the premium for persons enrolled in COBRA between April 1, 2021, and September 30, 2021, and seek the associated tax credits.
If the group health plan is not subject to federal COBRA, then mini-COBRA or comparable state continuation of coverage may apply, and the insurer will pay the premium between April 1, 2021, and September 30, 2021, and collect the associated tax credits. We may receive further guidance regarding operation of mini-COBRA or comparable state continuation of coverage that could impact this. We will update this FAQ accordingly.
Please note: The employer remains responsible for COBRA and mini-COBRA administration, such as eligibility, enrollment and termination decisions, and to provide timely notice to Harvard Pilgrim, identifying those mini-COBRA beneficiaries who are eligible for enrollment or who will be terminated.
Yes, retroactive coverage is allowed. However, an individual’s COBRA coverage effective date depends on whether the election is made under the previous federal extension for COVID-19 relief* (retroactive effective date) or the ARPA extended election period (effective date is on or after April 1), or both. If both are elected, a COBRA beneficiary’s effective date is retroactive to the date the individual lost coverage due to involuntary termination or reduction in hours, and the beneficiary will receive premium assistance beginning April 1 if the beneficiary timely elected under ARPA (60 days for federal COBRA), but the individual would be responsible for premiums owed prior to April 1, 2021 and after September 30, 2021, if applicable. IRS Notice 2021-58 (Examples 9 and 10) clarifies COBRA premium payments when a qualified beneficiary elects both retroactive COBRA continuation coverage under the federal extensions and ARPA COBRA premium assistance.
*See FAQ below titled “Federal deadline extensions for COVID-19 relief” for more details on the previous federal extensions.
For federal COBRA (20+ employees), the employer would pay and collect the tax credit (for coverage between April 1, 2021, and September 30, 2021). If the former employee is looking to retroactively enroll in federal COBRA prior to April 1, 2021, under the previous federal extension for COVID-19 relief rules, then the employer may seek back premiums to retroactively restore coverage. Please see IRS FAQ #58and IRS Notice 2021-58.
Federal deadline extensions
Harvard Pilgrim is taking measures to allow for the extended deadlines affecting COBRA continuation coverage, special enrollment periods, claims for benefits, appeals of denied claims, and external review of certain claims.
According to the federal guidance, the national emergency due to the COVID-19 outbreak began on March 1, 2020. At that point, timelines associated with COBRA, making enrollment changes due to special enrollment rights, submitting and appealing claims, and external claims review were paused. Pursuant to the EBSA Disaster Relief Notice, those timelines will resume the earlier of (a) one-year from the date which you were first eligible for relief under the federal guidance, or (b) the end of the outbreak period (which is 60 days after the end of the COVID-19 national emergency). The federal government has not yet announced the end of the national emergency. Additionally, IRS Notice 2021-58 clarifies how these federal extensions impact COBRA premium payments given that qualified beneficiaries have 60 days to elect COBRA after receipt of a COBRA election notice and COBRA premiums are due 45 days following that initial COBRA election (105 days total), with a 30-day grace period. This IRS Notice provides the following example:
IRS Example #3: (i) Facts. Individual C participates in Employer Z’s group health plan. Individual C has a qualifying event and is provided a COBRA election notice on August 1, 2020. When must Individual C elect COBRA continuation coverage and, if Individual C elects COBRA continuation coverage, when must Individual C make the initial COBRA premium payment? (ii) Conclusion. Individual C has until September 30, 2021 (one year and 60 days after August 1, 2020) to elect COBRA continuation coverage. If Individual C elects COBRA continuation coverage after September 30, 2020 (but on or before September 30, 2021) Individual C has until November 14, 2021 to make the initial COBRA premium payment (one year and 105 days after receipt of the election notice). If Individual C makes the initial COBRA premium payment on November 14, 2021, that premium payment would include the monthly premiums for August 2020 through October 2020. The November 2020 monthly COBRA premium payment would be due by December 1, 2021 (one year and 30 days after November 1, 2020), with premium payments due every month after that for the months Individual C is eligible for COBRA continuation coverage.
Employers should consult with their attorneys to determine the appropriate timing requirements and COBRA compliance under their plans. See Harvard Pilgrim’s FAQ above under “COBRA premium assistance (American Rescue Plan)” for information on how these federal deadline extensions interact with the American Rescue Plan’s COBRA rules.
Reduced hours and furloughed workers
Updated May 27, 2021
Fully insured employers in Connecticut, Massachusetts and New Hampshire
Until further notice, Harvard Pilgrim will temporarily relax the number of hours (from 20 to 0) an eligible employee currently enrolled in the plan must work to remain eligible for group health coverage. This will also apply to employees who have been furloughed (i.e., they are still employed but have been placed on a temporary leave of absence by their employer solely as a result of COVID-19 closures).
To be eligible, the employer’s group policy must be active with all premiums paid on a timely basis, including those for individuals on leave; in addition, one bona fide employee has to be and remain covered under the employer’s group policy. Coverage under these relaxed requirements is limited to current employees who, immediately prior to the date of this new requirement, were working at the employer’s premises and can no longer work due to the COVID-19 pandemic.
Fully insured employers in Maine
The same policy above applies to Maine employers; however, in accordance with the March 12, 2020 Supplemental Order Regarding Continuation of Group Health Coverage issued by Gov. Janet T. Mills (24-A M.R.S. § 471), no date has been specified for this policy to be terminated.
Coverage for furloughed employees depends on the employer’s decision; it would need to be permitted by the terms of the plan or the plan would need to be amended to allow for coverage. Employers should also check with their stop loss carrier to confirm that the stop loss carrier will permit such coverage.
COBRA and mini-COBRA
Note: This answer clarifies and replaces the answer from our 3/24/20 email.
Fully insured employers
Small groups (fewer than 20 employees): We will provide benefits to small employers in accordance with applicable “mini COBRA” under state continuation.
Large groups (more than 20 employees): We will provide benefits to large employers in accordance with federal COBRA law.
To be eligible, the employer’s policy must remain in effect and cover at least one employee for whom a COBRA qualifying event has not occurred. Harvard Pilgrim will not provide COBRA coverage unless there is at least one employee covered under the policy as a result of currently satisfying all applicable eligibility requirements, including, but not limited to, working the required number of hours.
Employees of self-insured businesses who lose their group coverage can elect COBRA in accordance with applicable law. COBRA eligibility decisions under self-insured plans are made by the employer as the plan administrator. Neither Harvard Pilgrim nor its affiliates are the plan administrator. Questions about COBRA under a self-insured plan should be addressed to the employer as the plan administrator.
Please note: Employees that lose group health coverage may in certain cases also obtain health coverage through the state Exchange program and may be eligible for premium assistance through the Exchanges.
Temporary relaxation of certain underwriting guidelines
Yes. Harvard Pilgrim will allow these employers a one-time special enrollment period during the employer’s current plan year and until the announced end of the national emergency.
New plan elections will be limited only to less-rich plan designs or “buy downs” (e.g., the employer’s current plan with a higher deductible)
Employers who want to offer a special enrollment period must notify Harvard Pilgrim 10 days in advance
The special enrollment period must be only for 30 days
This is an employer decision. We advise employers to consult your broker, consultant and/or legal counsel on the risk of waiving waiting periods mid-year. Self-insured customers should also consult their stop-loss carriers to ensure that such waiver is permitted.
Yes, if an employer temporarily lays off a member and then rehires the member, a deductible consumption will be credited to the member’s “account” if the rehire occurs within the same plan year as the date of lay off.
On a case-by-case basis, Harvard Pilgrim will consider a one-time extension of the statutory grace period for the payment of premiums to 30 days. In addition, Harvard Pilgrim is in compliance with all state specific regulations and published guidance in each of our markets. Your Account Executive is available to address your questions.
This is an employer decision. We advise employers to consult your broker, consultant and/or legal counsel on the risk of relaxing its minimum participation requirements mid-year. Self-insured customers should also consult their stop-loss carriers to ensure that such waiver is permitted.
Resources for members
Harvard Pilgrim has launched a series of complimentary virtual offerings to support members’ well-being–from webinars filled with useful, relevant tips, to live mindfulness sessions led by our team of expert instructors. Classes will be added each week covering subjects from stress to sleep. Learn more.
Members experiencing anxiety or stress related to the COVID-19 pandemic can call the Optum/United Behavioral Health emotional support help line toll free at (866) 342-6892. This service is free, open to anyone and available 24/7. Information and resources are also available at www.liveandworkwell.com.
Member coverage and care
Visit our member coronavirus page for questions and answers related to coverage for testing and treatment, information about self-care and other resources.
Harvard Pilgrim has launched a series of complimentary virtual offerings to support members’ well-being–from webinars filled with useful, relevant tips, to live mindfulness sessions led by our team of expert instructors. Classes will be added each week covering subjects from stress to sleep.