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.)

The California Department of Managed Health Care Social Services (DMHC) encourages health plans to take measures regarding telehealth and pharmacy visits in response to COVID-19.

Health plans should expedite any pre-authorization or pre-certification requirements for contracted providers to cover care delivered by telehealth.  The plan should either expedite review or relax requirements to allow the plan to more quickly approve offering services via telehealth.  Plans should also waive applicable cost-sharing for telehealth, notwithstanding that cost-sharing might apply if the provider delivered the care in person.

Plans should allow at least a 90 day maintenance supply of drugs unless the enrollee’s provider indicates a shorter supply of the drug is appropriate for the enrollee.  Plans should suspend prescription drug refill limitations where the enrollee’s provider indicates a refill is appropriate.  Plans should waive delivery charges for home delivery of prescription medications.  (APL 20-007, March 12, 2020.)

The California Department of Managed Health Care Social Services (DMHC) has ordered that health plans reimburse providers at the same rate regardless of the modality of delivery.  For services provided by telehealth, a health plan may not impose cost-sharing greater than if the services were provided in person.  Health plans must provide the same amount of reimbursement for a service provided by telephone as they would if the service is provided by video, as long as the modality by which the service is provided is medically appropriate for the enrollee.  (APL 20-009, March 18, 2020.)

The California Department of Managed Health Care Social Services (DMHC) has issued guidance regarding health plan services during self-isolation orders.  Health plans must continue to provide health care services and perform health plan functions.  Plans may delay some services such as elective surgeries or other non-urgent procedures if the referring or treating provider, or the health professional providing triage or screening services, has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee.

Plans can communicate with enrollees electronically and/or telephonically if the plan does not have personnel available to mail hard copy information.  Plans must maintain a record or log of such communications.  (APL 20-008, March 18, 2020.)