DATE: March 5, 2020
TO: All Full-Service Commercial and Medi-Cal Health Care Service Plans
FROM: Sarah Ream
Acting General Counsel
SUBJECT: APL-20-006 COVID-19 Screening and Testing
As the State of California responds to COVID-19, the Department of Managed Health Care (DMHC) is taking action to ensure that cost does not inhibit enrollees’ access to medically necessary screening and testing for COVID-19.
Waiver of Cost-Sharing Amounts
The DMHC directs all full-service commercial plans and full-service Medi-Cal plans to do the following:
1.Immediately reduce cost-sharing (including, but not limited to, co-pays,deductibles, or coinsurance) to zero for all medically necessary screening andtesting for COVID-19, including hospital (including emergency department),urgent care visits, and provider office visits where the purpose of the visit is to bescreened and/or tested for COVID-19.
2.Notify, as expeditiously as possible, the plan’s contracted providers that the planis waiving cost-sharing as described above.
3.Ensure the plan’s advice line/customer service representatives are adequatelyinformed that the plan is waiving cost-sharing as described above and clearlycommunicate this to enrollees who contact the plan seeking medically necessaryscreening and testing for COVID-19.
4.Prominently display on the plan’s public website a statement that the plan iswaiving cost-sharing for medically necessary screening and testing for COVID-19.
Protecting the Health Care Rights of More Than 26 Million Californians Contact the DMHC Help Center at 1-888-466-2219 or www.HealthHelp.ca.gov
Ensuring Enrollees Have Timely Access to Care
The DMHC reminds plans of existing California laws that require plans to ensure their enrollees are able to access medically necessary care in a timely fashion. These laws include:
•Covering all medically necessary emergency care without prior authorization,whether that care is provided by an in-network or out-of-network provider. (Healthand Safety Code section 1371.4.)
•Complying with the utilization review timeframes for approving requests forurgent and non-urgent services, as required by Health and Safety Code section1367.01. The DMHC strongly encourages plans to waive prior authorizationrequests for services related to COVID-19; at a minimum, plans are encouragedto respond to such requests more quickly than the timeframes required by law.
•Ensuring the plan’s provider networks are adequate to handle an increase in theneed for health care services, including offering access to out-of-networkservices where appropriate and required, as more COVID-19 cases emerge inCalifornia.
•Ensuring enrollees are not liable for unlawful balance bills from providers,including balance bills related to testing for COVID-19.
•Ensuring plans have 24-hour access to a person with the authority to authorizeservices and ensuring the DMHC has contact information for that person, asrequired by Health and Safety Code section 1371.4 and California Code ofRegulations, sections 1300.67.2.2 and 1300.68.01.
Finally, the DMHC encourages plans to act proactively to ensure enrollees can access all medically necessary screening and testing for COVID-19. To this end:
•Plans should work with their contracted providers to use telehealth services todeliver care when medically appropriate, as a means to limit enrollees’ exposureto others who may be infected with COVID-19, and to increase the capacity ofthe plans’ contracted providers.
•In the event of a shortage of any particular prescription drug, plans should waiveprior authorization and/or step therapy requirements if the enrollee’s prescribingprovider recommends the enrollee take a different drug to treat the enrollee’scondition.
The DMHC continues to closely monitor this situation and will issue further guidance as appropriate. In the meantime, if you have questions or concerns, contact your plan’s assigned licensing counsel.