Skip to content

Menu

LexBlog, Inc. logo
CommunitySub-MenuPublishersChannelsProductsSub-MenuBlog ProBlog PlusBlog PremierMicrositeSyndication PortalsAboutContactResourcesSubscribeSupport
Join
Search
Close

Required Coverage of COVID-19 Testing for Essential Workers in California

By Gary Baldwin, Kevin B. Kroeker & Alice Hall-Partyka on July 29, 2020
Email this postTweet this postLike this postShare this post on LinkedIn

On July 17th, the California Office of Administrative Law (“OAL”) approved an emergency regulation (effective until January 14, 2021) from the California Department of Managed Health Care (“DMHC”) that specifies COVID-19 diagnostic testing coverage requirements for California health care service plans. Medi-Cal managed care plans, Medicare Advantage plans, and specialized health plans are not subject to the regulation. The DMHC provided additional context to the emergency regulation in an all plan letter issued on July 23rd.

The regulation deems COVID-19 testing to be an urgent health care service during the California state of emergency. It also states that COVID-19 diagnostic testing is a medically necessary basic health care service for enrollees who are essential workers, regardless of whether the enrollee has symptoms of COVID-19 or a known or suspected exposure to a person with COVID-19. Essential workers are defined in the regulation to include a broad range of individuals working in the health care, emergency services, public transportation, congregate care, correctional, food service, and education sectors. Additionally, they include individuals who work in retail, manufacturing, agriculture, and food manufacturing that either have frequent interactions with the public or cannot regularly maintain at least six feet of space from other workers.

Between the regulation, all plan letter, and other applicable federal law, California health plans will need to comply with the following requirements for enrollees seeking COVID-19 testing:

1.    Enrollees With Symptoms of COVID-19 or Exposure to COVID-19:

  • The plan cannot impose: (i) utilization management or prior authorization requirements, (ii) cost-sharing requirements, or (iii) limitations on the number or frequency of tests received.
  • Enrollees can receive tests from either in-network or out-of-network providers.

2.   Essential Worker Enrollees Without Symptoms of COVID-19 or Exposure to COVID-19:

  • The plan cannot impose: (i) utilization management or prior authorization requirements or (ii) limitations on the number or frequency of tests received.
  • The plan must offer appointments within 48 hours, at a location within 15 miles or 30 minutes of the enrollee’s residence or workplace. Otherwise, the enrollee can access the test from any available provider, including out-of-network providers (in which case in-network cost-sharing amounts apply).
  • Ordinary cost-sharing requirements can be imposed.

3.   Other Enrollees Without Symptoms of COVID-19 or Exposure to COVID-19:

  • Plan can impose utilization management and prior authorization requirements, and testing is only required to be covered when determined to be medically necessary.
  • Where medically necessary, the plan must offer appointments within 96 hours, at a location within 15 miles or 30 minutes of the enrollee’s residence or workplace. Otherwise, the enrollee can access the test from any available provider, including out-of-network providers (in which case in-network cost-sharing amounts apply).
  • Ordinary cost-sharing requirements can be imposed.

If a health plan experiences difficulty in securing COVID-19 testing appointments for its enrollees due to regional or statewide shortages, it should contact its assigned reviewer at the DMHC.

For the diagnostic testing required under the regulation, health plans need to reimburse testing providers at contracted rates where available, the provider’s cash price (when required by federal law), or otherwise the reasonable and customary value of the services. Health plans also need to comply with Knox-Keene claim payment and submission timeframes and not delay or deny payment.

Any contractual change to delegate risk to a provider for COVID-19 diagnostic testing is considered a material change to the contract and needs to comply with the California provider bill of rights.

Photo of Gary Baldwin Gary Baldwin

Gary Baldwin is a partner in Crowell & Moring’s San Francisco office, where he practices in the Health Care Group. Gary’s practice is focused on health plan regulatory compliance, which includes compliance with the Knox-Keene Act, Affordable Care Act and California’s Medi-Cal program…

Gary Baldwin is a partner in Crowell & Moring’s San Francisco office, where he practices in the Health Care Group. Gary’s practice is focused on health plan regulatory compliance, which includes compliance with the Knox-Keene Act, Affordable Care Act and California’s Medi-Cal program requirements. His compliance practice ranges from licensing filings, to financial matters, to potential regulatory enforcement actions.

Read more about Gary BaldwinEmail
Show more Show less
Photo of Kevin B. Kroeker Kevin B. Kroeker

Kevin Kroeker is a partner in Crowell & Moring’s Los Angeles office, and is a former co-chair of the firm’s Health Care Group. He represents health care organizations on a wide range of state and federal regulatory matters and health care transactions. Kevin…

Kevin Kroeker is a partner in Crowell & Moring’s Los Angeles office, and is a former co-chair of the firm’s Health Care Group. He represents health care organizations on a wide range of state and federal regulatory matters and health care transactions. Kevin has more than 30 years of experience representing a diverse array of health care entities and stakeholders, including managed care plans and insurers, Medicare Advantage Organizations, Medicaid Managed Care plans, hospitals, medical groups and community clinics. Kevin has served on several nonprofit boards and he counsels nonprofit organizations in connection with governance and compliance issues. Kevin has guided numerous health plans and providers through the regulatory complexities of merger and acquisition transactions.

Read more about Kevin B. KroekerEmail
Show more Show less
Photo of Alice Hall-Partyka Alice Hall-Partyka

Alice Hall-Partyka is an associate in the firm’s Health Care and Corporate groups. Her practice focuses on assisting health care payors and providers on regulatory, compliance, and transactional matters. Alice also advises clients on employee benefit matters related to the Employee Retirement Income…

Alice Hall-Partyka is an associate in the firm’s Health Care and Corporate groups. Her practice focuses on assisting health care payors and providers on regulatory, compliance, and transactional matters. Alice also advises clients on employee benefit matters related to the Employee Retirement Income Security Act (ERISA) and the Internal Revenue Code.

Read more about Alice Hall-PartykaEmail
Show more Show less
  • Posted in:
    Health Care
  • Blog:
    Health Law
  • Organization:
    Crowell & Moring LLP
  • Article: View Original Source

LexBlog, Inc. logo
Facebook LinkedIn Twitter RSS
Real Lawyers
99 Park Row
  • About LexBlog
  • Careers
  • Press
  • Contact LexBlog
  • Privacy Policy
  • Editorial Policy
  • Disclaimer
  • Terms of Service
  • RSS Terms of Service
  • Products
  • Blog Pro
  • Blog Plus
  • Blog Premier
  • Microsite
  • Syndication Portals
  • LexBlog Community
  • 1-800-913-0988
  • Submit a Request
  • Support Center
  • System Status
  • Resource Center

New to the Network

  • The FTI Award Journal
  • International Dispute Resolution
  • China Law Update Blog
  • Law of The Ledger
  • Antitrust Law Blog
Copyright © 2022, LexBlog, Inc. All Rights Reserved.
Law blog design & platform by LexBlog LexBlog Logo