In response to COVID-19, Massachusetts has directed health insurance carriers to, among other things, relax cost-sharing and enhance telemedicine services. These directives are part of the Commonwealth's package of efforts to encourage early detection and treatment of COVID-19, and to slow the transmission of COVID-19. Massachusetts carriers have answered the call by enhancing benefits and services, in some cases beyond what the new directives require. Employers can play a key role by informing employees of these new benefits and encouraging employees to use the benefits.
Testing and treatment for COVID-19 presents many unique financial and logistic challenges. While early testing and treatment are crucial, it is also important that potentially infected individuals avoid contact with others, including at medical offices. Further complicating matters, individuals might avoid testing and treatment if faced with financial barriers, such as a high deductible, copayment, in-network requirements, prior authorization, or other burdensome cost-sharing or restrictions. High deductibles are of particular concern to many plan participants, as the spread of COVID-19 is happening at a time of year when most individuals have not yet exhausted their plan's deductible.
Massachusetts Guidance and Orders
In preparation for the COVID-19 spread, the Massachusetts Division of Insurance, on March 6, 2020, issued Bulletin 2020-02 in order to provide information to Massachusetts health insurance carriers about the Division's expectations regarding testing and treatment of COVID-19. In Bulletin 2020-02, the Division expressed its expectation that carriers:
- Establish dedicated help lines to respond to all calls about COVID-19 and keep covered members aware of providers who test/treat the virus, members' available benefits, and phone numbers that members can call for additional help;
- Promote tele-health options, including removal of applicable cost-sharing for such services, enabling covered members to seek screening, evaluation, diagnosis and/or treatment for COVID-19 in order to reduce the need for patients to visit medical offices where they may come in contact with COVID-19;
- Relax prior approval requirements and procedures so that members can get timely medically necessary testing or treatment, in accordance with DPH and CHC guidelines, if they are at risk of contracting COVID-19;
- Relax out-of-network requirements and procedures when access to urgent testing or treatment, in accordance with DPH and CDC requirements, is unavailable from in-network providers;
- Forego any cost-sharing (copayments, deductibles1 or coinsurance) for medically necessary COVID-19 testing, counseling and vaccinations at in-network doctors' offices, urgent care centers, or emergency rooms; and at out-of-network doctors' offices, urgent care centers, or emergency rooms when access to urgent testing or treatment, in accordance with DPH and CDC requirements, is unavailable from in-network providers; and
- Forego any copayments for medically necessary COVID-19 treatment, in accordance with DPH and CDC guidelines, at in-network doctors' offices, urgent care centers, or emergency rooms; and at out-of-network doctors' offices, urgent care centers, or emergency rooms when in-network alternatives are not available.
On March 15, 2020, Governor Charlie Baker issued an Executive Order applicable to Massachusetts health insurance carriers mandating the expansion of telehealth options in order to mitigate exposure to and the spread of COVID-19. In summary, the Executive Order requires carriers to:
- Allow in-network providers to deliver clinically appropriate, medically necessary covered services to members via telehealth;
- Ensure that rates of payment to in-network providers for services delivered via telehealth are not lower than rates of payment for traditional (in-person) methods, and notify providers of any instructions necessary to facilitate billing for telehealth services;
- Cover, without cost-sharing, medically necessary treatment delivered by telehealth related to COVID-19 at in-network providers; and
- Not impose prior authorization requirements on medically necessary treatment delivered via telehealth related to COVID-19 at in-network providers.
For more information on the impact of COVID-19 on the telehealth industry, be sure to check out our wide resources on the topic, including my colleague Ellen Janos' video and this post. For more information on the March 16 Executive Orders, see our analysis here.
To the best of our knowledge, carriers are swiftly responding to these directives, including by:
- Removal of cost-sharing for COVID-19 testing and treatment at in-network facilities and, where in-network services are not available, at out-of network facilities;
- Dedicated COVID-19 phone lines and online resource hubs;
- Removing cost-sharing for COVID-19 telehealth services; and
- Relaxed or waived prior-authorization requirements.
Many carriers have gone above and beyond the mandated requirements. Some additional COVID-19 enhancements we have heard of include:
- Options to fill prescriptions early and obtain a longer term supply (e.g. supply for 90 days rather than 30 days);
- Waiver for delivery fees for home delivery of prescription drugs;
- Removal of cost-sharing for any telehealth services, whether or not COVID-19 related, in order for members to avoid medical facilities; and
- Care packages for those diagnosed with COVID-19
Self-Insured Plans are NOT Required to Meet the New Requirements
Because these requirements are imposed on carriers, compliance by any self-insured group health plan is optional.
What Can Employers Do?
Although these are mandates on carriers, employers can play a key role during this crucial time. Some actions that employers can take include:
- Tell your employees. Employees' awareness (and use of) of these new benefits could make a huge impact on both individual and public health, and right now employers have the podium. Employees are paying keen attention to employer communications on topics such as telecommuting policies, business continuity, and leave. An employer communication about enhanced benefits is likely to be opened and read thoughtfully and may provide welcome relief to employees concerned about health care costs and access.
- Confirm that carriers are meeting the Massachusetts directives. If a carrier does not appear to implementing the required changes, demand compliance.
- Request that carriers go "above and beyond" by offering non-mandated benefits, such as enhanced prescription drug benefits and waiver of cost-sharing for all telehealth services (whether or not related to COVID-19).
- Offer enhanced benefits under self-funded arrangements, even though such arrangements are not required to do so.
- If an employer is outside of Massachusetts, ask carriers that similar benefits be offered, whether or not mandated by state law.
- Consider other implications of benefits changes generally, such as the need to update summary plan descriptions and whether election changes may be permitted due to the benefits enhancements.
1. As noted in our prior post, on March 12, 2020, the IRS issued notice 2020-15, providing that a health plan will not fail to be a Health Savings Account-compatible High Deductible Health Plan merely because it provides testing for and treatment of COVID-19 without a deductible or subject to a reduced deductible.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.