COVID-19 (Coronavirus) Testing; Issued 05/18/2020

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 2020-16 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary D. Anderson, Commissioner of Insurance Date: May 18, 2020 Re: COVID-19 (Coronavirus) Testing The Division of Insurance ("Division") issues this Bulletin to update Bulletin 2020-02 regarding COVID-19 testing and 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' coverage for COVID-19, also known as Coronavirus. Recognizing that members of the public may seek a variety of laboratory tests for SARS-CoV-2 or the novel Coronavirus, the virus that causes COVID-19, this Bulletin addresses coverage for COVID-19 testing that is medically necessary to diagnose or treat Coronavirus or other covered health conditions. # The Coronavirus Risk The public health, economic and societal consequences of the spread of the Coronavirus have dramatic impacts in the Commonwealth. It is essential that government and business leaders take all appropriate steps to safeguard the general public and well-being of the Commonwealth's citizens. Health insurance coverage plays a critical role in the public's actual and perceived access to and affordability of health care services. Coronavirus may impose unique risks to our 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. 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 Bulletin 2020-16 May 18, 2020 Page 2 of 3 Department of Public Health (“DPH”) and the Centers for Disease Control and Prevention (“CDC”). The Division also noted that as the situation evolved, the Division would issue further clarifying bulletins. Please note that the Division expects that Carriers do the following regarding testing: - Establish dedicated help lines to respond to all calls about the Coronavirus and keep covered members aware of providers who test/treat the virus, members’ available benefits, and phone numbers that members can call for additional help. - Relax prior approval requirements and procedures so that members can get timely medically necessary treatment, in accordance with DPH and CDC guidelines, if they are at risk of contracting the Coronavirus. - Eliminate prior approval requirements for antigen and polymerase chain reaction (“PCR”) testing for COVID-19, in accordance with DPH and CDC guidelines. - Relax out-of-network requirements and procedures when access to testing or urgent treatment, in accordance with DPH and CDC requirements, is unavailable from in-network providers. - Forego any cost-sharing (copayments, deductibles, or coinsurance) for medically necessary Coronavirus testing, counseling and vaccinations at in-network doctors’ offices, urgent care centers, or emergency rooms; and at out-of-network doctors’ offices, urgent care centers, or emergency rooms when access to testing or urgent treatment, in accordance with DPH and CDC requirements, is unavailable from in-network providers. ### COVID-19 PCR, Antigen and Antibody Testing At present, the Division is aware that there are three types of COVID-19 tests. - PCR tests look for the presence of the unique RNA of the novel Coronavirus in a patient. - Antigen tests look for a unique part of the novel Coronavirus, such as a specific protein on one of the unique novel Coronavirus spikes. - Antibody tests (also known as serology tests) look for presence of antibodies in a patient’s immune system that may fight off the novel Coronavirus. Please be aware that the Division expects Carriers to cover PCR or antigen tests designed to detect the presence of the novel Coronavirus when a covered patient has any symptom of COVID-19 or the patient has been exposed to COVID-19. The Division expects that specimen collection and lab processing costs associated with COVID-19 shall be reimbursed at a rate greater than the MassHealth rate when individually reimbursed. Carriers’ applicable specimen collection and lab processing practices shall otherwise apply. Regarding antibody tests, the Division expects Carriers to cover antibody tests for a covered patient when such tests are being conducted consistent with DPH and CDC guidance and are medically necessary in order to support treatment for COVID-19 or for treatment of another disease. ### Developing Coronavirus Testing Medical Necessity Guidelines Pursuant to M.G.L. c. 1760, §16(b), Massachusetts-issued insured health plans are required to provide coverage for health care services if (1) the services are a covered benefit under the insured’s Bulletin 2020-16 May 18, 2020 Page 3 of 3 health benefit plan; and (2) the services are medically necessary. Insured health plans that are accredited by the Division as managed care companies under M.G.L. c. 176O may employ utilization review systems in making decisions about whether services are medically necessary. Utilization review is defined in M.G.L. c. 176O as “a set of formal techniques designed to monitor the use of, or evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings.” Carriers should review all relevant medical necessity criteria and develop appropriate criteria for use in determining the medical necessity of all cases. Carriers may develop utilization review systems that apply to COVID-19 tests, provided that they are consistent with the provisions of M.G.L. c. 176O. Carriers may establish systems that evaluate the clinical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures or settings through ambulatory review, prospective review, second opinion, certification, concurrent review, case management, discharge planning, or retrospective review, provided that such systems comply with the requirements of M.G.L. c. 176O, §12 and 211 CMR 52.00. In addition, Carriers may require that a test be ordered by a treating physician based on health plan medical necessity criteria. Carriers that establish medical necessity criteria for COVID-19 testing should explain relevant testing provisions and procedures to members and all network providers so that they are aware of the requirements before members begin receiving health services. As required under M.G.L. c. 176O, §16(c), “[a]ny such medical necessity guidelines criteria shall be applied consistently by a [C]arrier or a utilization review organization and made easily accessible and up-to-date on a [C]arrier or utilization review organization’s website to insureds, prospective insureds and health care providers consistent with subsection (a) of section 12. If a [C]arrier or utilization review organization intends either to implement a new medical necessity guideline or amend an existing requirement or restriction, the [C]arrier or utilization review organization shall ensure that the new or amended requirement or restriction shall not be implemented unless the [C]arrier’s or utilization review organization’s website has been updated to reflect the new or amended requirement or restriction.” If a Carrier adopts new medical necessity guidelines associated with any COVID-19-related test, it should make these policies clear to all contracting providers, as well as covered employees and members in order to delineate when the Carrier will cover and pay for Coronavirus testing. ## 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, 2020-10, 2020-15 and 2020-16. 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. If you have any questions about this Bulletin, please contact Kevin Beagan, Deputy Commissioner for the Health Care Access Bureau, at (617) 521-7323.