RESPONSE TO COVID-19 PUBLIC HEALTH EMERGENCY (Commissioner's Order 01-2020)
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Emergency order directing health carriers in the District of Columbia to implement coverage and operational measures during the COVID-19 public health emergency; applies to all carriers offering health benefit plans in the District and to medical services obtained during the emergency.
Carriers must make medically necessary COVID-19 screening, testing, and treatment available with no deductible, coinsurance, copayment, or other cost-sharing, and shall not require prior authorization.
Carriers shall cover out-of-network charges (including cost-sharing and balance billing) for COVID-19 services unless an in-network option was first offered without unreasonable delay.
If a COVID-19 immunization becomes available per CDC guidance, carriers must immediately cover the vaccine and administration without cost-sharing.
Carriers must enhance telehealth coverage and ensure telehealth cost-sharing is no greater than for in-person services.
Carriers must allow early prescription refills and make formulary substitutions during shortages without prior authorization or extra cost, with limited exceptions for misuse-prone classes.
Carriers shall not cancel or non-renew health benefit plans without express consent from the Commissioner during the emergency.
Coverage Requirements During the COVID-19 Emergency
COVID-19 emergency coverage requirements
Covered when ALL of the following are met:
No deductible, coinsurance, copayment, or other cost-sharing of any kind; includes associated costs such as processing fees and clinical evaluations; no prior authorization
Department will institute expedited grievance procedures for adverse decisions
Immediate implementation upon CDC guidance
Reminder of District law on emergency coverage
Carriers to review telehealth programs with participating providers to meet increased demand
Exceptions allowed for misuse-prone drug classes (opioids, benzodiazepines, stimulants); no prior authorization or step therapy for substitutes except as noted
Notices must include links to DC Health guidance, state cost-sharing waivers, early refill policies, and be provided to customer service personnel, nurse help-lines, network providers, and the Commissioner
Prohibits unilateral cancellations/non-renewals during the public health emergency
The order allows limited exceptions for certain misuse-prone drug classes when implementing otherwise permissive policies on early refills and formulary substitutions. Specifically, while carriers must permit early prescription refills and make substitute medications available during supply shortages without prior authorization or step therapy, these accommodations may be restricted for opioids, benzodiazepines, and stimulants due to their potential for misuse.
Actions Required of Carriers and Providers
Prior‑authorization prohibited for COVID‑19 services and for most medication substitutions
Carriers shall not require prior authorization for medically necessary COVID-19 screening, testing, or treatment; carriers must also promptly make formulary substitutes available during medication shortages at no greater cost and without imposing prior authorization for those substitutes (exceptions for certain misuse‑prone drug classes apply).
- No prior authorization for medically necessary COVID-19 screening, testing, or treatment (including associated costs and clinical evaluations).
- When supply disruptions cause drug shortages, carriers must make substitutes available at no greater cost and without prior authorization.
- Exceptions for prior‑authorization/ substitution waivers may apply for misuse‑prone classes (opioids, benzodiazepines, stimulants).
No step therapy for substitute medications during shortages
Carriers shall not impose step therapy requirements when providing substitute medications due to supply chain disruptions; limited exceptions are allowed for drug classes subject to misuse.
- Prohibition on step therapy for substitutions made because of medication shortages.
- Exceptions may be made for opioids, benzodiazepines, and stimulants.
Operational provider actions for medication continuity and out‑of‑network billing
Providers should follow carrier and Department guidance to ensure timely access and avoid administrative obstacles: carriers must allow early refills, waive extra mail‑order fees, and request out‑of‑network providers to accept in‑network reimbursement for COVID‑19 services.
- Allow enrollees to obtain refills before the scheduled date to maintain adequate supply.
- Carriers shall waive additional fees for mail‑order prescription access.
- Out‑of‑network providers are requested to accept the highest in‑network reimbursement and to hold enrollees harmless for COVID‑19 screening, testing, and treatment.
Denial triggers for COVID‑19 services
Denial risk arises if services are not provided pursuant to CDC guidance or if carriers improperly impose cost‑sharing, prior authorization, or balance billing for medically necessary COVID‑19 services.
- Risk of denial or expedited grievance if services are not provided consistent with CDC guidance.
- Carriers must not impose deductible, coinsurance, copayment, or other cost‑sharing for medically necessary COVID‑19 screening, testing, or treatment.
- Coverage of out‑of‑network charges (including cost‑sharing and balance billing) is required unless an in‑network option was offered without unreasonable delay.
Policy Background
This emergency order responds to the COVID-19 public health emergency declared for the District of Columbia and aligns carrier operations with public health guidance. To ensure access to necessary care during the emergency, carriers are required to cover COVID-19 immunizations and related administration without cost-sharing when a vaccine becomes available per CDC guidance, expand telehealth coverage and maintain parity of telehealth cost-sharing with in-person care, and take prompt actions to preserve medication continuity when supply chain disruptions occur. The measures aim to remove financial and administrative barriers to screening, testing, treatment, vaccination, telehealth, and prescription access while the emergency is in effect.
Key Definitions and Authorities
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