The District of Columbia’s Acting Commissioner of the Department of Insurance, Securities and Banking (“DISB”), Karima Woods released Commissioner’s Order 01-2020 on March 20, 2020 (the “Order”). The Order applies to all carriers offering health benefit plans in the District and all medical services obtained during the ongoing public health emergency, as declared by DC Mayor Muriel Bowser. The Order requires the following:
- Screening, Testing and Treatment: Testing and treatment for COVID-19 or suspected COVID-19 or respiratory diseases and illnesses detected in the course of seeking screening, testing, or treatment for COVID-19, when a provider recommends such services pursuant to CDC guidelines, must be covered with no deductible, coinsurance, copayment, or other costsharing of any kind, including all associated costs such as processing fees and clinical evaluations. Carriers cannot require prior authorization. While enrollees may be encouraged to visit their primary care practitioners or other network providers for screening, testing and treatment, carriers must cover all out-of-network charges including cost-sharing and balance billing unless the enrollee was first offered the service in-network without unreasonable delay. DISB will be instituting expedited grievance procedures to review adverse decisions on requests for coverage for COVID-19 related health services.
- Network Adequacy: Out-of-network providers and facilities are “requested” to accept the highest of a carrier’s in-network reimbursement as full and final payment and to hold harmless enrollees who receive health care services as it relates to screening, testing and treatment of COVID-19. Providers are also “encouraged” to use the enrollee’s in-network laboratory facilities. Charges by out-of-network providers will be subject to DC’s existing statutory prohibition on overcharging during a public health emergency.
- Immunizations and Vaccines: If and when an immunization or vaccine becomes available for COVID-19 per CDC guidelines, carriers must immediately cover the cost for such services, including all associated costs of administration without cost-sharing.
- Emergency Care: The Order reminds carriers that District law requires coverage of emergency services, with network-level cost sharing regardless of the status of the emergency provider, whenever a prudent layperson, possessing an average knowledge of medicine and health, would believe that immediate medical attention is necessary to avoid serious jeopardy to health, serious impairment of a bodily function; or serious dysfunction of any organ or body part. As always, prior authorization may not be required for emergency services.
- Telehealth: Carriers are directed to enhance their coverage of telehealth services and review their telehealth programs with participating providers to ensure that the programs are robust and will be able to cover any increased demand. Cost sharing for telehealth services shall not be more than for in-person services.
- Access to RX Drugs: If supply chain disruptions result in shortages of medications that are on a carrier’s formulary, the carrier must act promptly to make substitutes available when necessary, at no greater cost to the patient and without imposing prior authorization or step therapy requirements. Carriers must also allow enrollees to obtain refills of their prescription medications before the scheduled refill date, so that enrollees are assured of maintaining an adequate supply, although exceptions may be made for drug classes subject to misuse, including opioids, benzodiazepines, and stimulants. Carriers must waive any additional cost to the enrollee of any fees associated with accessing prescriptions from a mail-order pharmacy.
- Utilization Review: When dealing with limited resources or unusual demand for health care services, carriers must prioritize the timely delivery of medically necessary services to enrollees. For both services related to COVID-19 and any other care that their enrollees might need, carriers must conduct any applicable utilization review and appeal processes “as expeditiously as possible.”
- Communication; Notice Requirements: Carriers are directed to give prompt notice to enrollees, providers, and the public of the measures they are taking to respond to the COVID-19 threat, including measures taken to comply with the terms of the Order. Carriers must ensure that the information shared is updated on an ongoing basis to remain current and accurate.
Carriers must provide clear and prominent notice that they are waiving cost sharing for medically necessary screening, testing and treatment for COVID-19, include links to DC Health’s website and guidance in their communications and on their website, and that early prescription refills are permitted. This notice must be posted prominently on the carrier’s website, provided to all customer service personnel and all nurse help-lines and similar programs, and delivered to all network providers and facilities. Carriers must provide the Commissioner of DISB with copies of all notices.
- Cancellation/Non-Renewals Generally Prohibited: Carriers cannot cancel or non-renew any health benefit plan without express consent from the Commissioner.
Locke Lord will continue to monitor these developments.
Visit our COVID-19 Resource Center often for up-to-date information to help you stay informed of the legal issues related to COVID-19.