Responding to COVID-19 Risks Following End of State of Emergency; Issued August 31, 2021

 # 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 MIKE KENNEALY SECRETARY OF HOUSING AND ECONOMIC DEVELOPMENT KARYN E. POLITO LIEUTENANT GOVERNOR EDWARD A. PALLESCHI UNDERSECRETARY OF CONSUMER AFFAIRS AND BUSINESS REGULATION GARY D. ANDERSON COMMISSIONER OF INSURANCE # BULLETIN 2021-08 To: Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations From: Gary Anderson, Commissioner of Insurance Date: August 31, 2021 Re: Responding to COVID-19 Risks Following End of State of Emergency The Division of Insurance ("Division") issues this Bulletin to provide guidance associated with COVID-19 testing, treatment, and vaccines to Commercial Health Insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and Health Maintenance Organizations ("Carriers"), and to clarify the Division's expectations regarding Carriers' coverage for COVID-19 following the end of the state of emergency declared on March 10, 2020. Please be aware that this Bulletin replaces guidance identified in Bulletins 2020-02, 2020-06, 2020-07, 2020-10, 2020-16, 2020-23, 2020-25, 2020-32, 2021-01, and 2021-03. With the May 28, 2021 declaration of a public health emergency due to the continuing threat of COVID-19 in the Commonwealth and the implementation of Section 70 of Chapter 260 of the Acts of 2020, the Division recognizes that COVID-19 risks will continue to exist, and this Bulletin delineates the Division's expectation that Carriers will continue to make access to appropriate testing, treatment, and vaccines available to eligible persons. # The COVID-19 Risk The public health and societal impact from the spread of COVID-19 dramatically impacted the Commonwealth, and the Division issued many bulletins since Governor Baker declared a state of emergency on March 10, 2020 to safeguard the general public and well-being of the Commonwealth's citizens. In numerous bulletins targeted to health insurance companies, the Division identified that Carriers should take all necessary steps to enable their covered members to obtain medically necessary and appropriate testing, treatment, and vaccines to help fight the spread of COVID-19. The state of emergency declared on March 10, 2020 ended as of June 15, 2021. As a result, many of the public health mandates that had been required since March of 2020 have been eliminated or Bulletin 2021-08 August 31, 2021 Page 2 of 3 modified. Please note that although the state of emergency has ended and the risk of COVID-19 transmission is reduced, it has not been eliminated. The Division expects that Carriers will enable Massachusetts residents to continue to have appropriate access to COVID-19 testing, treatment, and vaccination, without being subject to cost-sharing. ## Testing Carriers shall continue to cover COVID-19 testing, which shall include testing, without cost-sharing, for symptomatic individuals, for those persons identified as close contacts of persons with COVID-19 by state or local health officials, and for asymptomatic individuals under circumstances defined by guidelines established by the state's Secretary of Health and Human Services, the Department of Public Health, or federal COVID-19 guidance. As long as an individual qualifies under this criteria, Carriers are to provide coverage without the use of any utilization management. Except as provided by the guidelines established by the state's Secretary of Health and Human Services for asymptomatic testing, Carriers are not otherwise expected to cover tests that are solely intended for a covered person to go to work, school, or other locations. At present, the Division is aware that there are three types of COVID-19 tests. - PCR (Polymerase Chain Reaction) tests look for the presence of the unique DNA 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. The Division expects PCR and antigen tests to be covered by all health plans for eligible persons in accordance with the criteria listed above. The Division expects antibody tests to be covered by all health plans when the test is medically necessary in order to support treatment for COVID-19, or when a patient's immune system is compromised and/or knowledge of coronavirus antibodies may impact the future outcome of treatment. It is not considered medically necessary if a COVID-19 antibody test is to be used as part of "return-to-work" programs or any efforts not associated with treatment. Carriers are expected to reimburse providers at a level that is always higher than the MassHealth rate of reimbursement for the same test. ## Treatment In accordance with Section 70 of Chapter 260 of the Acts of 2020, Carriers are expected to provide coverage for all emergency, inpatient services, outpatient services, and cognitive rehabilitation services, including all professional, diagnostic, and laboratory services, related to the 2019 novel coronavirus, also known as COVID-19, whether provided by an in-network or an out-of-network provider, without the use of prior authorization processes. Bulletin 2021-08 August 31, 2021 Page 3 of 3 Carriers should cover, without patient cost-sharing, all claims where COVID-19 is a listed diagnosis¹ or that use Code B94.8 (“Sequelae of other specified infectious and parasitic diseases”) as a listed diagnosis because a Code B94.8 claim should be considered related to COVID-19. Carriers are expected to cover services that may be related to reactions to the COVID-19 vaccine, but may apply cost-sharing, since these services are not considered related to the treatment of COVID-19. For all covered COVID-19 treatment, Carriers are required to waive all cost-sharing. Reimbursement to network providers should be based on the terms that Carriers have established within contracts established with network providers. When treatments are performed by out-of-network providers, Carriers are expected to negotiate “single-case” agreements with providers so that the covered person is never balance billed for approved treatment provided by out-of-network providers. ## Vaccines Carriers are expected to provide coverage for all COVID-19 vaccines, without cost-sharing and without the use of any utilization management according to guidelines established by appropriate federal or state public health authorities. Carriers are expected to reimburse providers at a level that is always higher than the MassHealth rate of reimbursement for any vaccine administered. ## Carriers Acting As Administrators 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 this Bulletin 2021-08. Plan sponsors should be made aware of the continued risk associated with COVID-19, and Carriers should do all they can to encourage plan sponsors to follow the provisions of this Bulletin for non-insured health benefit coverage in Massachusetts. If you have any questions about this Bulletin, please contact Kevin Beagan, Deputy Commissioner for the Health Care Access Bureau, at (617) 521-7323. ¹ COVID-19 diagnoses include, but are not limited to, the following and should include any additional codes as the CDC billing guidance provides in the future: o J12.82, Pneumonia due to COVID-19, Pneumonia due to SARS-CoV-2 o M35.81, Multisystem inflammatory syndrome, Multisystem inflammatory syndrome in children, Pediatric inflammatory multisystem syndrome when billed with B94.8 o M35.89, other specified systemic involvement of connective tissue when billed with B94.8 o Z11.52, encounter for screening for COVID-19 o Z20.822, contact with and (suspected) exposure to COVID-19, Contact with and (suspected) exposure to SARS-CoV-2