Health Insurance

COVID-19 telehealth services

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The Department of Managed Health Care (DMHC) issues instructions to covered health plans regarding telehealth services.  During the COVID-19 state of emergency, a health plan may not exclude coverage for certain types of services or categories of services because they are provided via telehealth, if the provider determines the services can be delivered effectively by telehealth.  During the COVID-19 state of emergency, a health plan may not place limits on covered services because they are provided by telehealth if such limits would not apply if the services were provided in person.

A health plan may not require enrollees to use the plan’s telehealth vendor or a different provider from the one the enrollee usually sees if the provider agrees to deliver services via telehealth and the enrollee consents to receiving services via telehealth.

Plans cannot impose credentialing or approval requirements specific to telehealth if the provider is otherwise appropriate to deliver services and the health plan would cover the provider’s services if the provider had provided services in person.

Health plan cannot require providers to use a particular platform or modality to deliver services via telehealth.  However, providers must consider their obligation to protect confidentiality of their patients.  (APL 20-013, April 6, 2020.)

COVID-19 PrEP-AP enrollment

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The California Department of Public Health has issued instructions regarding the Pre-Exposure Prophylaxis Assistance Program (PrEP-AP) to minimize exposure to COVID-19 and maintain coverage.  For clients with expiring eligibility or expired eligibility back to March 1, PreP-AP is extending eligibility for 90 days to June 30, 2020.

However, for clients in a Gilead Assistance Program, Gilead is not extending eligibility.  Clients enrolled with expiring eligibility should submit a re-enrollment application with income documentation to Gilead prior to their eligibility ending to avoid a lapse in coverage.

If clients are unable to obtain their medication or submit a re-enrollment application before their eligibility expires, Gilead can provide the pharmacy override on a case-by-case basis.  If Gilead does not allow a medication dispense, PrEP-AP may approve an override on a case-by-case basis.

Clients enrolled in Gilead’s Patience Assistance Program and Copayment Assistance Program can receive up to a 90-day fill of medication as long as there is eligibility throughout the 90 day time period.  Clients in Gilead’s Copayment Assistance Program can only receive a 90 day dispense if their insurance allows for a 90-day prescription fill.  Pharmacies must contact Gilead to get an override code.  This is in effect until April 30, 2020.

Clinical providers are encouraged to consider converting PrEP to virtual if their agency has the capacity.  PrEP-AP can reimburse telemedicine using the same billing code as for an in person visit. Providers are encouraged to reach out to client to inform them that in-person appointments are changing to telemedicine.

Providers are also asked to postpone services that require person-to-person interaction but will maintain access to in-person visits when needed based on the client’s symptoms such as acute HIV or a sexually transmitted infection.  Laboratory testing for people on PrEP with good adherence and no symptoms can usually be postponed for 3 months.  (Management Memorandum 20-08, March 20, 2020.)

COVID-19 ADAP enrollment

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The California Department of Public Health has issued instructions regarding the AIDS Drug Assistance Program (ADAP) to minimize exposure to COVID-19.  For clients with expiring eligibility or expired eligibility back to March 1, ADAP is extending eligibility for 90 days to June 30, 2020.

New or lapsed clients can enroll over the phone.  New or lapsed clients will be required to provide documentation of eligibility.  Workers can email the client so the client can respond with enrollment and supporting documentation.

ADAP will now have early medication refills and has extended the dispense quantity to 90-day fills.  (Management Memorandum 20-06, March 16, 2020.)

Covered California opening enrollment

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In response to COVID-19, effective Friday March 20, Covered California opened the health insurance exchance to any eligible uninsured individuals who need health care coverage through the end of June.  After selecting a plan, coverage will begin on the first of the following month, which means individuals losing job-based coverage will not have a gap in coverage.

Consumers who sign up through CoveredCA.com may find out that they are eligible for Medi-Cal, which they can enroll in online.  Those eligible for Medi-Cal can have coverage that is immediately effective.

The Department of Managed Care and the California Department of Insurance will provide guidance to health plans on the special-enrollment period, which will include off-exchange health plans.

All plans offered through Covered California and Medi-Cal provide telehealth options.  All medically necessary screening and testing for COVID-19 is free of charge.  (Covered California Press Release, March 20, 2020.)

COVID-19 screening and testing for commercial health insurance

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The California Department of Insurance (CDI) has issued a directive to all insurers providing commercial health coverage regarding steps to ensure that cost does not interfere with availability of COVID-19 testing.

CDI directs all insurers providing commercial health coverage to: 1) reduce cost-sharing to zero for all medically necessary screening and testing for COVID-19, 2) notify the plan’s contracted providers that the plan is waiving cost-sharing, 3) ensure that the plan’s advice nurse line and customer service representatives are so informed, 4) inform the insurer’s call center staff to advise their insureds to call their provider’s office or advice nurse line for instructions about how to best access care for screening and treatment of COVID-19, and 5) prominently display on their websites that cost-sharing for medically COVID-19 screening and testing is waived.

CDI reminds insurers that they: 1) must cover all medically necessary emergency care without prior authorization, 2) comply with utilization review timeframes for approving requests for urgent and non-urgent services, 3) ensure their provider networks are adequate to handle an increase in need for services and 4) ensure enrollees are not liable for balance billing.

CDI encourages plans to work with contracted providers to use telehealth services when medically appropriate, and to 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.  (CDI Bulletin, COVID-19 Screening and Testing, March 5, 2020.)

COVID-19 screening and testing for health plans

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The California Department of Managed Care (DMHC) has issued a directive to all commercial health plans and full service Medi-Cal plans regarding steps to ensure that cost does not interfere with availability of COVID-19 testing.

DMHC directs all commercial health plans and full service Medi-Cal plans to: 1) reduce cost-sharing to zero for all medically necessary screening and testing for COVID-19, 2) notify the plan’s contracted providers that the plan is waiving cost-sharing, 3) ensure that the plan’s advice line and customer service representatives are so informed, and 4) display on their websites that cost-sharing for medically COVID-19 screening and testing is waived.

DMHC reminds plans that they must: 1) cover all medically necessary emergency care without prior authorization, comply with utilization review timeframes for approving requests for urgent and non-urgent services, 2) ensure their provider networks are adequate to handle an increase in need for services, 3) ensure enrollees are not liable for balance billing, and 4) ensure 24-hour access to a person with authority to authorize services.

DMHC encourages plans to work with contracted providers to use telehealth services when medically appropriate, and to 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.  (APL 20-006, March 5, 2020.)