BULLETIN 2020-02
ACCESS TO COVERAGE FOR OHIOANS IMPACTED BY THE COVID-19 VIRUS
Effective March 11, 2020
This Bulletin pertains to all insurance companies and other entities transacting the business of insurance in the State of Ohio that have delivered, issued, or used policies of sickness and accident insurance and/or travel insurance in Ohio.
The purpose of this Bulletin is to notify companies of the request of the Superintendent of Insurance (“Superintendent”) that companies ensure members have access to needed health care services to test for and treat COVID-19 by promoting access to coverage.
To date, there have been 3 confirmed cases of COVID-19 in Ohio. As the situation develops, issuers can help ensure access to coverage by considering any necessary and appropriate methods for reducing barriers to access for these services.
Travel Insurance
Issuers of travel insurance are reminded that unless a specific exclusion applicable to COVID-19 applies, a travel insurance policy that covers sickness, accident, disability, or death occurring during travel must cover such risks related to COVID-19 according to the terms of the policy. Many travel insurance policies also must cover cancellation or interruption of a trip or event, emergency transportation and/or costs of returning to the United States for further treatment pursuant to the terms of the policy.
Health Insurance Coverage
Most comprehensive major medical policies offered in the state of Ohio provide access to coverage for ambulatory services, emergency services, hospitalization, laboratory tests and prescription drugs when medically necessary, subject to the terms of the policy. Certain short-term-limited- duration or other excepted benefit plans are not required to provide these services. Issuers should have customer service representatives and helplines readily available to provide helpful and accurate information to assist consumers with questions about the terms of their coverage with respect to COVID-19 related services.
Issuers of sickness and accident policies are also reminded of the following obligations under federal and state insurance law:
Emergency Services
Emergency care must be covered without preauthorization and must be covered at the same cost sharing level as if provided in-network. Health insuring corporations providing coverage in Ohio must also cover out-of-network emergency services without balance billing. Additionally, issuers should be advised that when applying the prudent layperson standard to services for emergency care, COVID-19 and the associated symptoms must be considered.
Utilization Management
Issuers are encouraged to proactively evaluate the appropriateness of applying utilization management techniques that are permitted under Ohio law or the terms of a policy of sickness and accident insurance to services for testing or treatment of COVID-19.
Telemedicine
Issuers that provide coverage for services delivered via telemedicine are expected to provide such coverage for COVID-19 testing and treatment. Issuers that do not currently provide this coverage are encouraged to implement early adoption of the Ohio law requirements effective January 1, 2021. Under those requirements, issuers are prohibited from excluding coverage for a service that is otherwise covered under the health plan solely because it is delivered as a telemedicine service. Issuers are also required to cover telemedicine services on the same basis and to the same extent that the plan provides coverage for in-person services.
Appeals and External Review
Issuers must afford insureds the opportunity to submit adverse benefit determinations for internal appeal and the opportunity to request external review by the Ohio Department of Insurance if applicable. Requests for appeal or external review must be expedited if medically appropriate, as required by Ohio law.
Access to Providers
Issuers should ensure that provider networks are adequate to handle testing and care for COVID-19. In certain instances, if the issuer does not have providers in its network to meet these needs, the issuer must provide access to out-of-network providers at in-network cost sharing.
Prescription Drug Supply
Issuers that cover prescription drugs must provide access to a standard and expedited formulary exceptions process for non-formulary prescription drugs. Issuers are also encouraged to consider allowing insureds to access prescription drug supplies beyond the typical supply limit with appropriate exceptions for controlled substances, even if the scheduled refill date has not yet been reached, as medically appropriate.
Accessible and Accurate Information
Issuers are reminded to keep consumers informed regarding available benefits, to ensure that nurse helplines are appropriately staffed, to respond timely to inquiries, and to make necessary and useful information available on their websites.
No filing submissions are necessary to effect the Superintendent’s requests. Any insurer unable or unwilling to comply with this request must inform the Ohio Department of Insurance of the reasons for its inability or unwillingness to comply within five working days from the effective date of this Bulletin. Responses shall be directed to:
Ohio Department of Insurance
50 W. Town Street; Suite 300
Columbus, Ohio 43215
Directors.office@insurance.ohio.gov
Superintendent of Insurance
Jillian Froment
Director