In response to COVID-19, the California Department of Health Care Services (DHCS) has issued a reminder to all Medi-Cal managed care health plans (MCPs) regarding existing contractual requirements and state and federal laws to ensure access to medically necessary services in a timely manner.
These provisions include: 1) covering all medically necessary emergency care without prior authorization, 2) complying with utilization review timeframes for approving requests for urgent and non-urgent services 3) ensuring provider networks are adequate to handle an increase in need for services, 4) ensuring members are not liable for balance billing, 4) ensuring 24-hour access to a plan representative with authority to authorize services, 5) offering members and providers the option to use telehealth services to deliver care when medically appropriate. MCPs must act proactively to ensure members can access all medically necessary screening and testing of COVID-19. MHPs should work with contracted providers to use telehealth services when medically appropriate.
DHCS also allows reimbursement for virtual communication, which includes brief communication with another practitioner or patient who cannot be physically present.
MCPs must approve transportation requests in a timely manner if a member, who may be infected with COVID-19, needs to be seen in person and requests transportation. Plans are responsible for determining the appropriate mode of transportation required to meet the members needs, paying special attention to those with urgent needs such as dialysis or chemotherapy.
MCPs must ensure that members are at a facility appropriate to the level of care they require.
MCPs must act proactively to ensure member access to needed prescriptions. MCPs should 1) cover maintenance medications at a minimum 90 day supply (note that limits certain opioids still apply), 2) covering or waiving any prescription delivery costs MCPs should also waive prior authorization and/or step therapy requirements if the provider recommends the enrollee take a different drug and there is a shortage of any particular prescription drug, 3) approving out of network overrides for beneficiaries who may be temporarily outside the plan service area because of COVID-19, 4) setting refill-too-soon edits for maintenance medications to 75 percent or less to authorize early refills when 75 percent of the prior prescription has been used, 5) expanding pharmacy benefit coverage for all disinfectant solutions and wipes that can be processed through the pharmacy benefits system, and 6) ensuring 24/7/365 call center support for pharmacies, providers and members.
DHCS is allowing flexibility for Health Home Programs services to be conducted in a way that prioritized safety. DHCS encourages MCPs and their contracted Community-Based Care Management Entities to implement telephone and video call assessments. DHCS is suspending its current in-person visit requirement until further notice.
DHCS is seeking additional flexibility by exploring options to temporarily waive Medicaid and Children’s Health Insurance Program requirements under Section 1135. DHCS will issue additional guidance if waiver requests are granted. (Department of Health Care Services Memorandum, COVID-19 Screening and Testing, March 6, 2020, updated March 16, 2020.)