Notice Regarding Coronavirus (COVID-19) Insurance Coverage; Notice 2020-03
[50 Pa.B. 1788]
[Saturday, March 21, 2020]
The Insurance Department (Department), in collaboration with the Department of Health, is issuing this bulletin to assist individuals and entities regulated by the Department addressing health insurance related services that may arise in the context of the ongoing coronavirus (COVID-19) outbreak. All health insurers, other insurance industry representatives and other interested parties are encouraged to review the latest Commonwealth information about COVID-19 released by the Department of Health at www.health.pa.gov.
Recognizing the critical role that health insurance coverage plays in the public's actual and perceived access to and affordability of health care services, the Department urges health insurers providing coverage to residents of this Commonwealth to take the following immediate measures related to the potential impact of COVID-19.
1. Preparedness. Health insurers should review their internal processes and operations to ensure that they are prepared to address COVID-19 cases in this Commonwealth, including by providing insureds with information and timely access to all medically necessary covered health care services. As the COVID-19 situation continues to evolve, health insurers should continually assess their readiness and make any necessary adjustments.
2. Information Access for Insureds. Access to accurate information and avoiding misinformation are critical. Therefore, health insurers are asked to inform insureds of available benefits, quickly respond to inquiries about coverage, and consider revisions needed to streamline responses and benefits for insureds. Health insurers are encouraged to make all necessary and useful information available on their web sites and staff their consumer assistance lines accordingly.
3. Testing for COVID-19. The Department expects medically prescribed diagnostic testing for COVID-19 to be covered without the use of prior authorization requirements that might ordinarily apply to diagnostic testing. The Department also urges health insurers to waive any cost-sharing for COVID-19 laboratory tests so that cost-sharing does not serve as a barrier to access to this important testing and recognizes that many health insurers have already taken this important step. In addition, health insurers are asked to waive the cost-sharing for in-network provider office visits, in-network urgent care center visits and emergency care services, when testing for COVID-19.
4. Balance Billing and Surprise Balance Bills. Health insurers are urged to assist insureds in accessing in-network or publicly funded health services to avoid balance billing and surprise balance bills. Where out-of-network services are provided, the Department and the Department of Health expect that health insurers and providers will work together to avoid imposing costs on insureds.
5. Telehealth Delivery of Services. Given that COVID-19 is a communicable disease, some insureds may prefer to use telehealth services instead of in-person health care services. Health insurers are encouraged to review their respective participating telehealth service provider arrangements, provide coverage of costs related to telehealth services and to be prepared to meet any increased demand for that means of delivery.
6. Network Adequacy and Access to Out-of-Network Services. Health insurers are asked to verify their provider networks are adequate to handle a potential increase in the need for health care services related to COVID-19. If a health carrier does not have sufficient health care providers in its network with the appropriate training and experience to meet the particular health care needs of its insureds, health insurers are reminded that they should cover out-of-network services as if an in-network provider were available. (See 28 Pa. Code §§ 9.679 and 9.681(c) (relating to access requirements in service areas; and health care providers).)
7. Utilization Review. Timely decision making is essential to responding appropriately to COVID-19, and it is particularly important with respect to utilization review. Health insurers are strongly encouraged to ease preauthorization requirements, so that they are not a barrier to access necessary treatment for COVID-19, and health insurers should be prepared to expedite utilization review and appeal processes for services related to COVID-19.
8. Access to Prescription Drugs. Health insurers are asked, where appropriate, to make expedited formulary exceptions and to permit the temporary use of out-of-network pharmacies (at in-network cost-sharing) in the event of medication shortages at in-network pharmacies. To the extent consistent with clinical guidelines, and in a manner calculated to ensure an enrollee's ability to maintain a 30-day supply of a prescription drug, the Department encourages insurers to cover refills even when the scheduled refill date has not been reached. (This recommendation does not apply to prescription drugs with a high likelihood of abuse, such as opioids.) Health insurers are also encouraged to implement medication synchronization immediately (in advance of the effective date of Act 46 of 2019) so that insureds may efficiently fill prescriptions.
9. Coordination with Self-Funded Business. While not under the Department's regulatory jurisdiction, the Department encourages health insurers to coordinate closely with the business they administer on behalf of employers who self-fund their health benefits to ensure consistency in access across all forms of coverage.
10. Information Sharing. To ensure that public health officials and the public are adequately informed about what the health insurance industry is doing in response to COVID-19, the Department asks that health insurers provide information on the steps they are taking in response to this bulletin. Health insurers may send that information to email@example.com.
In sum, to protect the public health, health insurers are asked to identify and remove barriers to testing and treatment for COVID-19. Health insurers must be prepared to address COVID-19 cases in this Commonwealth and the Department extends its appreciation to health insurers in working with the Commonwealth to address this public health challenge. Since the COVID-19 situation continues to evolve, health insurers should continually assess their readiness and be prepared to make any necessary adjustments.
Health insurers are advised to contact the Office of the Commissioner, Insurance Department, 1326 Strawberry Square, Harrisburg, PA 17120, firstname.lastname@example.org with questions regarding this bulletin.
JESSICA K. ALTMAN,
[Pa.B. Doc. No. 20-430. Filed for public inspection March 20, 2020, 9:00 a.m.]
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