Coverage for COVID-19 Treatment and Out-of-Network Emergency and Inpatient Reimbursement During the COVID-19 Health Crisis
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Directs Massachusetts commercial carriers and HMOs on coverage, cost-sharing waivers, prior authorization, and payment rates for medically necessary testing and treatment of COVID-19 during the Commonwealth's emergency order; applies to commercial insurers, Blue Cross and Blue Shield of Massachusetts, Inc., and HMOs.
This Bulletin 2020-13 modifies Bulletin 2020-02 regarding medically necessary Coronavirus treatment and expands expectations for carriers during the duration of the Emergency Order.
Coverage and Clinical Criteria
Coverage and payment criteria during Emergency Order
Covered when ALL of the following apply during the duration of the Governor's Emergency Order:
Chunk support: 4
Chunk support: 4,5
Chunk support: 4,6
Chunk support: 6
Chunk support: 6
This Bulletin does not change standards for medically necessary Coronavirus treatment outside the scope of the changes described here; standards set in Bulletins 2020-02, 2020-04, and 2020-10 remain in effect. The Bulletin specifically modifies Bulletin 2020-02 to expand expectations applicable during the duration of the Governor's Emergency Order, including expanded coverage and waivers of cost-sharing for outpatient, emergency department, and inpatient COVID-19 treatment and clarifying reimbursement and balance-billing expectations.
Reimbursement and Coding Notes
Provider Responsibilities and Prior Authorization
Prior authorization waived during Emergency Order
During the Governor's Emergency Order, carriers are expected to forego prior authorization requirements for medically necessary emergency department and inpatient COVID-19 services and for outpatient COVID-19 treatment provided by in‑network providers; concurrent reviews may proceed as permitted by law.
- Applies to emergency department and inpatient services (in- or out-of-network) and to outpatient treatment when delivered by in-network providers.
Coverage for out-of-network acute care hospital services (no prior auth)
Carriers are expected to provide coverage for medically necessary emergency department and inpatient services rendered by out-of-network acute care hospitals without any prior authorization requirements.
- Includes professional, diagnostic, and laboratory services delivered in acute care hospitals.
- Expectation aligns with DPH and CDC guidelines referenced by the Division.
Align services with DPH and CDC guidance
Medically necessary COVID-19 testing and treatment must be provided in accordance with Massachusetts DPH and CDC guidance; carriers are expected to provide coverage and forego cost‑sharing for such services during the Emergency Order.
- Guideline alignment applies to outpatient, emergency department, and inpatient services as specified in the Bulletin.
- Carriers must follow DPH and CDC guidance when determining covered services and cost‑sharing waivers.
Prior authorization and review expectations for ED and inpatient COVID‑19 care
Carriers are expected to forego prior authorization requirements for medically necessary emergency department and inpatient COVID-19 services (including when delivered by out-of-network acute care hospitals); carriers may proceed with concurrent reviews only as permitted by law.
- Expectation covers professional, diagnostic, and laboratory services for ED and inpatient care.
- Concurrent reviews of stays remain permitted where allowed by law.
Policy Background and Purpose
The Division notes the significant public health impact of COVID-19 and directs carriers to ensure timely access to medically necessary testing and treatment in alignment with Massachusetts Department of Public Health (DPH) and Centers for Disease Control and Prevention (CDC) guidance. To protect public health and support access during the Commonwealth's emergency, the Bulletin requires carriers to provide coverage and forego cost-sharing for medically necessary outpatient COVID-19 treatment when delivered by in-network providers, and to provide coverage and forego cost-sharing for medically necessary emergency department and inpatient COVID-19 treatment whether provided in- or out-of-network; it also permits concurrent reviews as allowed by law.
Definitions and Scope
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