Coverage for COVID-19 Treatment and Out-of-Network Emergency and Inpatient Reimbursement During the COVID-19 Health Crisis; Issued 04/09/2020

[LOGO] COMMONWEALTH OF MASSACHUSETTS Office of Consumer Affairs and Business Regulation DIVISION OF INSURANCE 1000 Washington Street, Suite 810 • Boston, MA 02118-6200 (617) 521-7794 • Toll-free (877) 563-4467 http://www.mass.gov/doi CHARLES D. BAKER GOVERNOR KARYN E. POLITO LIEUTENANT GOVERNOR MIKE KENNEALY SECRETARY OF HOUSING AND ECONOMIC DEVELOPMENT EDWARD A. PALLESCHI UNDERSECRETARY OF CONSUMER AFFAIRS AND BUSINESS REGULATION GARY D. ANDERSON COMMISSIONER OF INSURANCE ### BULLETIN 2020-13 To: All Commercial Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary D. Anderson, Commissioner of Insurance Date: April 9, 2020 Re: Coverage for COVID-19 Treatment and Out-of-Network Emergency and Inpatient Reimbursement During the COVID-19 Health Crisis The Division of Insurance (“Division”) issues this Bulletin 2020-13 to supplement the provisions of recent bulletins, including Bulletin 2020-02 (“Addressing COVID-19 [Coronavirus] Testing and Treatment”); Bulletin 2020-04 (“Emergency Measures to Address and Stop the Spread of COVID- 19 [Coronavirus]”), and Bulletin 2020-10 (“Credentialing and Prior Authorization During the COVID-19 [Coronavirus] Health Crisis”) to provide information to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations (“Carriers”) about the Division’s expectations regarding Carriers’ appropriate coverage of treatment for COVID-19, also known as Coronavirus. On April 9, 2020, Governor Baker issued an “Order Expanding Access to Inpatient Services” (“Emergency Order”) that is effective as of April 9, 2020. This Bulletin provides guidance to Carriers and the Group Insurance Commission regarding how to implement the Emergency Order. It is intended to establish standards so that medically necessary emergency department and inpatient services to treat Coronavirus are as widely available as possible, and so that the cost of those services does not pose a barrier to Massachusetts residents receiving care during the period of the Commonwealth’s public emergency. ### The Coronavirus Risk The public health and societal impact resulting from the spread of the Coronavirus has dramatically impacted the Commonwealth. In order to minimize the impacts going forward, it is essential that government and business leaders take all appropriate steps to safeguard the general public and well- Bulletin 2020-13 April 9, 2020 Page 2 of 3 being of the Commonwealth's citizens. Health insurance coverage plays a critical role in the public's actual and perceived affordability of and access to health care services. Coronavirus may impose unique risks to the insurance market that Massachusetts has not faced for at least a generation. Therefore, the Division is notifying Massachusetts Carriers that it expects them to take all necessary steps to enable their covered members to obtain medically necessary and appropriate testing and treatment that will help fight the spread of this disease. ## Treating Coronavirus As noted in Bulletin 2020-02, the Division expects Carriers to communicate prevention, testing, and treatment options to covered persons in accordance with guidelines from the Massachusetts Department of Public Health (DPH) and the Centers for Disease Control and Prevention (CDC), such as guidelines regarding how and when to contact your local board of health or health care provider. As noted in Bulletin 2020-04, the Division expects Carriers to forego prior authorization requirements and cost-sharing (deductibles, coinsurance or copayments) for medically necessary Coronavirus treatment when delivered via telehealth by in-network providers. As this situation evolves, and informed by guidance from the DPH and CDC, the Division may issue further bulletins on this topic. Please note that this Bulletin 2020-13 modifies Bulletin 2020-02 regarding medically necessary Coronavirus treatment. Beyond what is noted in Bulletin 2020-02 and Bulletin 2020-04, the Division expects Carriers, during the duration of Governor Baker's Emergency Order, to do the following: - When delivered by in-network providers, Carriers are to provide coverage and forego any cost-sharing (deductibles, coinsurance or copayments) for medically necessary outpatient Coronavirus treatment, including professional, diagnostic, or laboratory services, in accordance with DPH and CDC guidelines. - When delivered by either in-network or out-of-network providers, Carriers are to provide coverage, and forego any cost-sharing (deductibles, coinsurance or copayments) for medically necessary emergency department and inpatient Coronavirus treatment, including professional, diagnostic or laboratory services, in accordance with DPH and CDC guidelines. - All in-network providers are to be reimbursed at the contractually allowed amounts for those members with whom the Carrier has a contract and who participate in a member's health plan. The standards for medically necessary Coronavirus treatment not related to this Bulletin remain unchanged from what was stated in Bulletins 2020-02, 2020-04, and 2020-10. Carriers would be permitted to proceed with concurrent reviews of stays as permitted by law. ## Coverage for Coronavirus Treatment in Acute Care Hospitals The Division encourages patient access to available medically necessary services in order to address issues that may arise due to potential inpatient acute hospital bed shortages during the state of emergency. The Division therefore expects that Carriers, without any prior authorization requirements, will provide coverage for medically necessary emergency department and inpatient services rendered by out-of-network acute care hospitals, including professional, diagnostic, or laboratory services, in accordance with DPH and CDC guidelines. Bulletin 2020-13 April 9, 2020 Page 3 of 3 ## Payment for Out-of-Network Emergency and Inpatient Treatment for Coronavirus Carriers are expected to reimburse out-of-network acute care hospitals and the out-of-network providers providing emergency department and inpatient services, including professional, diagnostic or laboratory services, at or for patients of such hospitals in the following manner for emergency department and inpatient services to treat Coronavirus in accordance with DPH and CDC guidelines: - For acute care hospitals and providers, as defined in M.G.L. c. 111, § 1, providing services at or for patients of such hospital with whom the Carrier has a contract, but who do not participate in a member's health plan, medically necessary services shall be reimbursed at the provider's contracted rate with the Carrier for delivered services; - For acute care hospitals and providers, as defined in M.G.L. c. 111, § 1, providing services at or for patients of such hospital with whom the Carrier does not have a contract, unless a Carrier is otherwise directed by the Division, medically necessary services shall be reimbursed at a rate equal to 135 percent of the rate paid by Medicare for those services in the provider's geographic region. Under the Emergency Order, providers, as defined in M.G.L. c. 111, § 1, shall not be permitted to balance bill the insured for any amount above the Carrier's reimbursement. ## Carriers Acting As Administrators Due to the public health crisis caused by Coronavirus, when Carriers are acting as administrators for employment-sponsored non-insured health benefit plans, the Division expects Carriers to encourage plan sponsors to take steps that are consistent with the provisions of Bulletins 2020-02, 2020-04, and 2020-10. Plan sponsors should be made aware of the public health risks to all Massachusetts residents, and Carriers should do all they can to encourage plan sponsors to take steps to remove barriers to accessing medically necessary testing, diagnosis, counseling, and treatment of Coronavirus and to encourage full coverage for out-of-network inpatient services. If you have any questions about this Bulletin, please contact Kevin Beagan, Deputy Commissioner for the Health Care Access Bureau, at (617) 521-7323.