ALL PLAN LETTER
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 and testing for COVID-19, including hospital (including emergency department), urgent care visits, and provider office visits where the purpose of the visit is to be screened and/or tested for COVID-19.
2. Notify, as expeditiously as possible, the plan’s contracted providers that the plan is waiving cost-sharing as described above.
3. Ensure the plan’s advice line/customer service representatives are adequately informed that the plan is waiving cost-sharing as described above and clearly communicate this to enrollees who contact the plan seeking medically necessary screening and testing for COVID-19.
4. Prominently display on the plan’s public website a statement that the plan is waiving cost-sharing for medically necessary screening and testing for COVID- 19.
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. (Health and Safety Code section 1371.4.)
• Complying with the utilization review timeframes for approving requests for urgent and non-urgent services, as required by Health and Safety Code section 1367.01. The DMHC strongly encourages plans to waive prior authorization requests for services related to COVID-19; at a minimum, plans are encouraged to 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 the need for health care services, including offering access to out-of-network services where appropriate and required, as more COVID-19 cases emerge in California.
• 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 authorize services and ensuring the DMHC has contact information for that person, as required by Health and Safety Code section 1371.4 and California Code of Regulations, sections 1300.67.2.2 and 1300.68.01.
Proactive Steps
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 to deliver care when medically appropriate, as a means to limit enrollees’ exposure to others who may be infected with COVID-19, and to increase the capacity of the plans’ contracted providers.
• In the event of a shortage of any particular prescription drug, plans should waive prior authorization and/or step therapy requirements if the enrollee’s prescribing provider recommends the enrollee take a different drug to treat the enrollee’s condition.
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.