Addressing COVID-19 (Coronavirus) Testing and Treatment
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This Bulletin sets the Division of Insurance's expectations for Massachusetts commercial health carriers regarding coverage, cost-sharing, prior authorization, network flexibility, and member communication for medically necessary testing and treatment related to COVID-19, affecting carriers and their covered members in Massachusetts.
Carriers are expected to forego cost-sharing for medically necessary COVID-19 testing, counseling, vaccinations and treatment under specified conditions.
Carriers should relax prior authorization and out-of-network requirements to ensure timely access to testing and treatment in accordance with DPH and CDC guidance.
Carriers must establish dedicated help lines and promote telehealth, including removing applicable cost-sharing for telehealth services related to screening, evaluation, diagnosis, and treatment of Coronavirus.
Coverage expectations for COVID-19 services
Division expectations for carrier actions
The Division expects carriers to take the following actions to ensure access to medically necessary COVID-19 services:
All actions are expected of carriers as described in the Bulletin.
Coverage for services related to Coronavirus applies only when two conditions are met: (1) the service is a covered benefit under the insured's health benefit plan, and (2) the service is medically necessary. Carriers retain the authority to perform utilization review to evaluate medical necessity as defined in statute. When utilization review is used, carriers may require documentation supporting medical necessity, but they should also develop appropriate exceptions for insureds at significant risk of contracting dangerous viruses such as the Coronavirus.
Provider-facing requirements and flexibilities
Relax prior authorization for timely COVID-19 care
The Division expects carriers to relax prior authorization requirements and procedures so members can get timely medically necessary testing or treatment in accordance with DPH and CDC guidelines.
Relax network/step-therapy barriers when in‑network access is unavailable
Carriers should relax out-of-network requirements and step-therapy procedures when access to urgent testing or treatment is unavailable from in-network providers so members can obtain timely care per DPH and CDC requirements.
Review medical necessity criteria and create exceptions for high‑risk insureds
Carriers should review all relevant medical necessity criteria and develop appropriate exceptions for insureds at significant risk of contracting dangerous viruses such as the Coronavirus; documentation supporting medical necessity may be required for utilization review.
Ensure service is a covered benefit and medically necessary
Coverage only applies when the service is both a covered benefit under the insured’s health benefit plan and is medically necessary; carriers may employ utilization review to evaluate medical necessity and deny services that do not meet plan coverage or medical necessity standards.
Key terms
Background and purpose
COVID-19 (Coronavirus) presents a public health threat that can necessitate testing, urgent care, and other medically necessary services. Ensuring timely access to testing and treatment reduces barriers to care and helps limit further spread. The Division expects carriers to follow guidance from the Massachusetts Department of Public Health and the CDC when implementing policies and to consider exceptions for members at elevated risk.
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