BULLETIN 2020-016 – COVID-19 DETERMINATIONS AND CHARGES

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Russell Toal ,11. - 51 Off"CEOf­ McW MeXICO .... _..,.,.,. o,...,.,,,cr DEPUTY SUPERINTENDENT Robert E. Doucette, Jr. V} : f; :ri · .. r·r·1 .. •·1 • ::e:: ::"" r' : ______________________________ rd1""'=_-., __ 1-_...,.1;?j ::? (:·!.f:'!'Ht.JJ, . I ti ;r... : ·r,·, .-·, ; ;{\ BULLETIN 2020-016 August 4, 2020 [
 nt,i! TO: ALL HEALTH INSURANCE CARRIERS, GROUP HEALTH PLANS, HEALTH MAINTENANCE ORGANIZATIONS, AND NON-PROFIT HEALTH CARE PLANS RE: COVID-19 TESTING DETERMINATIONS AND CHARGES The rules of the OSI require health insurers licensed in the state to remove cost ban-iers to COVID-19 testing and treatment by waiving any associated cost sharing. Prohibited cost sharing obligations include co-pays, deductibles and coinsurance. The expectation of the OSI has been and is that insurers will affomatively notify their contracted providers that there must be no charges to an insured patient for COVID-19 testing or treatment. Under Subsection B of 13.10.13.12 NMAC, provider charges for an office visit, and any other administrative fee relating to the administration of a COVID-19 test, are part of the billing for the test and the insurer and the provider must waive any associated cost sharing for such billings. These requirements apply regardless of whether the COVID-19 test comes back positive or negative. The federal Families First Coronavirus Response Act prohibits prior authorization or other medical management requirements on COVID-19 testing. In addition, we interpret the OSI's provisions on network adequacy to require insurers to have in-network testing services available for covered members. In Bulletin 2020-009 we provided guidance on how to treat emergency testing and treatment during the COVID-19 Public Health Emergency. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 I Satellite Phone: (505) 322-2186 I Toll Free: (855) 4 - ASK- OSI www.osi.state.nm.us B U L l- E -la I N 2 0 2 0 - 0 1 6 P a g e 2 Under Sec. 6001 of FFCRA and Sec. 3202 of CARES Act, FDA approved or authorized "diagnostic tests" for COVID-19 are to be covered by all group health plans and plans providing individual coverage with no cost sharing. CMS has clarified that this also applies to self-funded plans, all group and individual insurers (including grandfathered and transition plans) on and off a Health Insurance Exchange, and to state or local govetanment health plans. The federal rules were effective March 18, 2020 and continue through the end of the Public Health Emergency. CMS recently clarified that for a COVID-19 diagnostic test to be covered by the insurer a health care provider must make a determination that the individual's condition or circumstance watrants a test. This deteimination must be made by a medical professional but it need not be a physician and it need not be a medical professional directly involved in the routine care of the individual. So, for example, a test ordered by a provider in an urgent care center, emergency room or at a drive-through testing site is acceptable, even though the provider is not the medical professional normally caring for the individual. CMS notes that an individual can receive several tests if the additional testing is determined to be indicated by a medical professional. The federal provisions also require at-home COVID-19 tests to be covered if a medical professional reviews information provided: by the individual and determines that an at-home test is warranted and appropriate. Under the federal amendments to the Public Health Act, the states are the primary enforcers of the COVID-19 provisions. CMS has noted that "[s]tates can provide more protection for consumers" The most recent CMS FAQs have caused some confusion among payers and providers, in part because this new federal griidance states that "related items", i.e., any items related to the test or needed for the evaluation as to whether a test is needed, including x-rays, Jab fees and physician or facility fees, must be covered if a visit results in a COVID-19 diagnostic test. This is a CMS interpretation of the federal law, but it is not the position of the OSI. Our position is that the costs associated with making a determination as to whether a test is indicated or not are to be covered and shall not be subject to any patient cost sharing. It is not in the public's interest to impose cost barriers to individual testing, and we do not want to discourage individuals from seeking an assessment as to whether a test is appropriate. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us B LI I. L E T I N 2 0 2 0 - O l 6 l) a g e i3 Despite the stance outlined immediately above, we agree with the CMS statement in its last FAQs that "broad-based screening not based on individual symptoms or exposure - like, return to work requirements or surveillance testing - are not included in the requirement" for testing coverage. We have received questions related to coverage of students retuiing to school or universities, and our instruction has been that only those students whom a medical professional determines meet the federal and state testing appropriateness guidelines should be tested. When such a determination is made, the costs associated with both the assessment and the test are to be covered. So, we would not expect that all students retaining to a college would be covered for testing, but an individual student who may have been exposed to the virus should have a determination of testing appropriateness and the costs of such an assessment must be covered by an insurer. This same principle would apply to child care settings and with child care workers. Tlie same general principles apply to "back to work" testing. If an employer wishes to require such testing, it is not orir or CMS's expectation that such testing must be covered by an insurer. Again, there may be individual employees who should be tested because of their unique situation, but coverage of all employees would rarely be indicated and an insurer is not responsible for covering such testing. However, insurers should recognize that a medical professional is within their professional discretion to decide that individuals who are in highrisk environments (e.g., healthcare sites, correctional facilities, long-term care and congregate settings, etc.), or who are members of special populations at increased risk, should undergo screening for testing appropriateness, iirespective of whether the individual to be tested presents with clinical indications, and insurers must give deference to providers as to whether a test is ordered. As stated above, in such a situation both the assessment cost and the test cost are to be covered. We note that if an employer is self-insured and wishes to have the testing of all employees covered by their plan, it is within their discretion to do so. We want to underscore that the position of the OSI is that carriers should give deference to providers on whether an individual should be tested, but we also recognize that under no circumstances should a provider be administering the test to all who present. When a carrier Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd HE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us B U L L E T I N 2 0 2 0 - C) l 6 Page4 believes a provider is inappropriately or fraudulently administering testing, the carrier has an obligation to report this to the proper authorities for investigation and action (where indicated). The decision as to reasonableness of charges from a provider is one that resides with the insurer exclusively, but a decision to deny coverage of charges must be reasonable and must not result in cost sharing obligations being imposed on the individual who sought or received the COVID-19 test. We do not and will not regulate provider payment amounts but we will take action aggressively if consumers are being inappropriately charged. Carriers are reminded that both our and the federal guidance makes it clear that costs related to testing must be covered; so, for example, if there is an office visit or facility fee charged as pait of the testing it must be covered, and no cost sharing can be applied to the individual taking the test. We have received calls from providers who say that their contracts with insurers require them to charge a co-pay for any and all office visits, but you will recall that in March each of you provided direction to your network providers that no co-pays were to be charged for COVID-19 testing or treatment. It may be time for you to remind your contracted providers of this exception to co-pay charge requirements. For non-COVID-19 related services, cost sharing obligations (such as specific service or deductible obligations) may apply, even if the non- COVID-19 services were provided at the same time. However, there should not be an office visit or facility charge co-pay if the non-related services were incidental to the prime reason for the visit, namely, receiving an assessment as to COVID-19 testing appropriateness. Carriers are reminded of the request made through OSI Bulletin 2020-006 regarding Consumers Affected by COVID-19 and the Emergency Public Health Measures. In that Bulletin, carriers are asked to refrain from cancelling or non-renewing policies of businesses and individuals negatively impacted by the disruption due to the non-payment of premiums during this public health emergency, or at a minimum, provide extended grace periods for payment of premiums. Since we are still in a state of public health emergency please be sure that you are taking action to avoid coverage cancellations. For those who are losing coverage, please refer them to our website, the YESNM website of HSD7Medicaid, or the beWellnm website. You may use the attached flyer to make the information readily available. Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Bl'vd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 i Satellite Phone: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us B ll I. L E T I N 2 0 2 0 - 0 1 6 'l' a %%" e 5 We recognize that these are difficult, challenging and fluid times for us all. We hope that you have taken all necessaiy steps to ensure the safety and health of your own employees, and we thank you for your cooperation on this issue, on coverage of both telemedicine and telehealth and premium forbearance. We value the paitnership you have shown New Mexico. Our goal is to build on that success. We hope you will accept and follow tis Bulletin in that light. ISSUED this 4' day of August, 2020. Attachments Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 Satellite Pl'ione: (505) 322-2186i Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us times y g F:;"?'ft During the Pandemic, EVERYONE QUALIFIES for coverage. We will help you get covered for free or at a low-cost to you. Start Here Do you qualify for Medicaid? g*4gnding an your ingome and family iizg you may qualify for Medicaid To apply call 1-855-637-65% or apply online at the YES New Mexico portal 1-855-637-6574 yes.state.nm.us lfyoudontquakifyforMedicaid you %;qjp661 bu 1-833-862-3935 -844-728-7896 No matter what, you can get covered. MEDICAID I H U M A N m SE RVICES New Mexico qua y y %'t:'!'xsayz Federal Poverty Level iFPL], is a measure ofincome used to determine eligibility for Medicaid and the Children's Health Insurance Program (CHIP), aswekl as premium subsidies and cost-sharing reductions (cost-sharing subsidiesl in the exchange, and other federal programs. Light Blue = Could qualify for a discounted premium. Blue = Could qualfy for a premium tax credit and cost-sharing reduction. Dark Blue = Could qualify for Medicaid coverage. H U M A N m S E RVIC ES Individuals Family of 2 Family of 3 Family of 4 Family of 5 O-100% FPL $1,064 $1,437 $1,810 $2,184 $2,557 138% FPL $1468 $.1 983 $2,498 $3,013 $3,529 139% FPL $1,469 $1,984 $2,499 $3,015 $3,530 240% FPL $2,552 $3,449 $5,240 $6, 137 300% FPL $3,190 $4,311 $5,430 $6,55 € $7,671 400% FPL $4,256 $5,748 $7,240 $8,736 $10 228 OVer 400% FPL $4,256+ $5,748+ $7,240+ $8,736+ $10 228+ Family of 6 $2,93C) $7,032 $8,790 $11,720 $11,720+ The FPL amounts are valid through March 31, 2021. Ifyou think you qualify or are unsure what you qualify for, give us a call so we can help! MEDICAID I H U M AN 'ffSERVICES New Mexico'*- Medical <ole 1-855-637-6574 1-833-862-3935 1-844-728-7896 yes.state.nm.us bewellnm.com nmmip.org NMHX 001 0A/2a cobertura de salud. Durante la pandemia, TODOS CALIFICAN para la cobertura. Le ayudaremos obtener una cobertura gratuita o de bajo costo para usted. Comience aqui ,5Califica para Medicaid? [)ependiendo de sus ingresos y ek tamario desufamilia puedecalificarparaMedicaid Paraapkicar llameall-855-637-65%o lkene una sokicitud en la pagina web de YES New Mexico 1-855-637-6574 yes.state.nm.us zEs usted elegible para inscribirse en un plan a trav6s de beWellnm? Si no califica para Medicaid ahora puede calificar para un seguro privado gratuito o de bajo costo a traves de beWeklnm Si recientemente perdi6 su trabajo ovio una reducci6n en sus ingresos, llameal 1-833-862-3935 para ver si califica para cobertura. 1-833-862-3935 bewellnm.com Ot'ra edical IrimraffEi ffi tra76;s-de beWell?m. todosen Nuevo .Mixico pueden obtener coo gturg, g5 d'6The New MeSTt'a Medical Insurance -844-728-7896 nmmip.org Pase lo que pase, usted puede estar cubierto. MEDICA}D I HUMAN SERVICES nm' New Mexicol Medical <oW El Nivel Federal de Pobreza [FPL] es una medida deingresos utilizada para determinar la elegibilidad para Medicaid y el Programa de Seguro M6dico para Ninos [CHIP), asi como subsidios de primas y reducciones de costos compartidos (subsidios de costos compartidosl en el intercambio, y otros programas federales. AzuL claro = Podria calificar para una prima con descuento. Azul = Podria calificar para un cr6dito fiscal premium y una reducci6n de costos compartidos. Azul Oscuro = Podria calificar para la cobertura de Medicaid. A H U M A N 'f' SERVICES Individuos Familia de 2 Familia de 3 FamiLia de 4 Familia de 5 O-100% FPL $1064 $1 ,A37 $1,8'l0 $2,184 $2 557 138% FPL $1,468 $1,983 $2 498 $3,013 $3,529 139% FPL $1,469 $1,984 $2,499 $3,015 $3,530 240% FPL $2,552 $3,449 $5,240 $6, 137 300% FPL $3,190 $4,311 $5,430 .$6,550 $7 67'l 400o/o FPL $4,256 $5,748 $7,240 $8;736 $10,228 OVer 400% FPL $4,256+ $5,7 48+ $8,736+ $10,228+ Familia de 6 $2,930 $4,045 $7,C132 $8,790 $11,72 € $11,72C)+ Los montos de FPL son validos hasta el31 de marzo del 2021. Si cree que califica o no esta seguro para qu6 cakfica, kUmenos para que podamos ayudarto! MEDICAID nm" ,l New Mexico ! 1-855-637-6574 1-833-862-3935 1-844-728-7896 yes.state.nm.us bewellnm.com nmmip.org NMHXOm ail/20