Updated Guidance for COVID-19 PCR and Antigen Testing; Issued 07/08/2020

[LOGO] CHARLES D. BAKER GOVERNOR KARYN E. POLITO LIEUTENANT GOVERNOR 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 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 2020-23 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary D. Anderson, Commissioner of Insurance Date: July 8, 2020 Re: Updated Guidance About COVID-19 (Coronavirus) PCR and Antigen Testing The Division of Insurance (“Division”) issues this Bulletin to update Bulletins 2020-02 and 2020-16 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 polymerase chain reaction (“PCR”) or antigen testing 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 PCR and antigen testing that is appropriate to diagnose or treat the Coronavirus. This guidance, in addition to all current federal guidance regarding COVID-19 testing, is to be followed by all Carriers covering health services in Massachusetts. ## 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 appropriate steps to enable their covered members to obtain appropriate testing and treatment that will help fight the spread of this disease. Bulletin 2020-23 July 8, 2020 Page 2 of 3 ## Coverage for PCR and Antigen Testing The Division expects Carriers to communicate prevention, testing, and treatment options to covered persons. Carriers are expected to cover PCR and antigen testing in the following situations: ### Symptomatic Individuals: All symptomatic individuals in Massachusetts, as identified by a healthcare provider, even those with mild symptoms. Symptoms of COVID-19 include: - Fever or chills; - Signs of a lower respiratory illness (e.g., cough, shortness of breath, lowered oxygen saturation); - Fatigue, sore throat, runny nose or congestion, headache, body aches/myalgia, or new loss of sense of taste or smell; - Other less common symptoms can include gastrointestinal symptoms (e.g. nausea, vomiting, diarrhea), rash, inflammatory conditions such as "COVID toes", and thromboembolic events; - In elderly, chronically ill, or debilitated individuals such as residents of a long-term care facility, symptoms of COVID-19 may be subtle such as alterations in mental status or in blood glucose control; and - Children with multisystem inflammatory syndrome. ### Close Contacts of Confirmed or Clinically Diagnosed COVID-19 Cases: All individuals in Massachusetts identified as a close contact by a Local Board of Health, the Massachusetts Department of Public Health ("DPH"), the Community Tracing Collaborative, or a healthcare provider. Close contact is defined as: a) Being less than 6 feet from a confirmed or clinically diagnosed COVID-19 case for at least 10-15 minutes, while the case was symptomatic or within the 48 hours before symptom onset. Close contact can occur anywhere, examples include caring for, living with, visiting, or sharing a healthcare waiting area or room with a confirmed or clinically diagnosed COVID-19 case OR b) Having direct contact with infectious secretions of a confirmed or clinically diagnosed COVID-19 case (e.g., being coughed on) while not wearing recommended personal protective equipment (e.g., gown, gloves, facemask, eye protection). ### Asymptomatic Cases: All individuals upon admission to a Massachusetts healthcare facility, including but not limited to, a hospital operated or licensed by the Department of Public Health or Mental Health, long-term acute care hospital, or skilled nursing facility. Testing may be conducted pre-admission/pre-procedure and does not need to be contemporaneous with the admission. As identified by the Baker Administration, it is imperative that appropriate testing be available according to the identified guidelines so that the Commonwealth can appropriately combat the spread of the disease now and in the future. Numerous new testing locations have opened, including "pop-up" locations and drive-through sites, where persons that have met eligibility requirements receive appropriate PCR and antigen tests to identify COVID-19. Bulletin 2020-23 July 8, 2020 Page 3 of 3 ## Procedures for PCR and Antigen Testing Please note that the Division expects that Carriers do the following to make PCR and antigen testing available: - Establish network arrangements with all dedicated “pop-up” locations and drive-through sites so that in-network PCR and antigen testing services are available for covered members. - Ensure access to COVID-19 tests intended for at-home testing (including tests where the individual performs self-collection of a specimen at home), when the test is ordered by a provider. - Eliminate prior approval requirements for antigen and PCR testing for COVID-19 in accordance with this Bulletin 2020-23 when eligible or when a medical provider has made an individualized clinical assessment to determine whether the test is medically appropriate for the individual in accordance with current accepted standards of medical practice. Carriers may not employ medical necessity reviews or require an order from a provider directly responsible for providing care to the patient. - Relax out-of-network requirements and procedures for access to testing or urgent treatment - Forego any cost-sharing (copayments, deductibles, or coinsurance) for Coronavirus testing, counseling, and vaccinations. Carriers are also expected to establish all appropriate contractual, billing, and other administrative arrangements to reimburse providers for the cost to collect specimens and conduct appropriate PCR and antigen tests. Such arrangements may allow for the bundling of billed specimen and PCR or antigen test costs, provided that these are clearly explained in writing to all billing providers. Such arrangements should also allow for the billing of an additional payment to a provider for the collection of a specimen when the provider: (1) has a qualified ordering clinician present at the specimen collection site available to order appropriate COVID-19 tests; (2) ensures that the test results (and any initial follow-up counseling, as appropriate) are provided to the member, either directly or through the member’s ordering clinician; and (3) does not separately bill for a medical visit or encounter for the actual specimen collection, or for the order of the initial results of the COVID-19 test. At all times, 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, and that Carriers’ applicable specimen collection and lab processing practices shall otherwise apply. ## 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 follow all applicable federal guidance and to encourage plan sponsors to take steps that are consistent with the provisions of Bulletins 2020-02, 2020-04, 2020-10, 2020-15, 2020-16, and 2020-23. 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 appropriate 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.