Updated Guidance Regarding Coverage and Reimbursement for Out-of-Network Emergency, Ambulance and Inpatient Services During the COVID-19 Health Crisis
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Guidance to Massachusetts commercial insurers, Blue Cross and Blue Shield of Massachusetts, and HMOs on coverage, reimbursement, prior authorization, and balance-billing rules for COVID-19-related emergency, inpatient, ambulance, rehabilitation and home health services during the public health emergency and under Chapter 260/Order No. 61.
This Bulletin supplements and in some cases supersedes prior Bulletins (2020-10 and 2020-13) and clarifies expectations under Chapter 260 and COVID-19 Order No. 61 regarding coverage and reimbursement for COVID-19 services.
Insurers must provide coverage without member cost-sharing for emergency, inpatient and cognitive rehabilitation services related to COVID-19 at in-network and out-of-network providers per Chapter 260, Section 70.
Out-of-network medically necessary services in applicable regions must be reimbursed at 135% of Medicare rates when the carrier has no contract with the provider, except when the carrier does have a contract and the provider does not participate in the member's plan (then use the contracted rate).
Providers licensed by DPH are prohibited from balance-billing insured members for amounts above the Carrier's reimbursement.
Carriers are expected to suspend prior authorization requirements for transfers and certain out-of-network facility services during the public health crisis, while retaining the ability to perform concurrent and retrospective review.
COVID-19 Coverage and Reimbursement Criteria
COVID-19 coverage and reimbursement criteria
Covered and reimbursed when the following conditions are met:
ALL of the following
ONE of
- If the carrier has a contract with the acute care hospital or provider but the provider does not participate in the member's specific health plan, reimburse at the provider's contracted rate with the carrier.
- If the carrier does not have a contract with the acute or non-acute facility/provider, reimburse medically necessary services at 135% of the Medicare rate for the provider's geographic region during periods when one or more regions are Tier 2 or higher under the DPH Resurgence Planning and Response Framework, unless otherwise directed by the Division.
ALL of the following
- Carriers are expected to suspend prior authorization requirements for medically necessary emergency department and inpatient services and for transport costs to transfer patients to lower levels of needed care during the public health crisis.
- Carriers should enable patient transfers and reimburse associated transport costs as needed to manage inpatient capacity and patient acuity.
ALL of the following
- Facilities and home health agencies must notify the patient's carrier within 48 hours of admission or of the first home health visit.
- Carriers may perform concurrent and retrospective utilization review despite suspension of prior authorization requirements.
ALL of the following
- Out-of-network 135% Medicare reimbursement applies only during periods when one or more Commonwealth regions are designated Tier 2 or higher under the DPH Resurgence Planning and Response Framework.
- The Division will notify carriers weekly about regional status; carriers are deemed in compliance if they implement required system adjustments within 21 days of Division notification.
Reimbursement Benchmark and Regional Trigger
| 135% Medicare | Reimbursement rate benchmark for out-of-network non-contracted acute and non-acute facility services for COVID-19 in applicable regions. |
Prior Authorization, Notification, and Review Requirements
Suspend prior authorization for ED/inpatient care and transport during the public health crisis
Carriers are expected to suspend prior authorization requirements for medically necessary emergency department and inpatient services, and for transport costs when transferring patients to lower levels of needed care during the public health crisis; carriers may conduct concurrent and retrospective reviews after admission or after home health care has begun.
- Suspend prior authorization systems that apply to transfers and transport costs to lower levels of needed care.
- Enable patient transfers and reimburse transport costs to move patients among facilities as needed.
Notify Carrier within 48 hours; carriers may conduct concurrent/retrospective review
Facilities (rehabilitation hospitals and skilled nursing facilities) and home health agencies must notify the patient’s Carrier within 48 hours of admission to the facility or of the first home health visit; Carriers retain the right to conduct concurrent and retrospective review despite being unable to require prior authorization.
- Facility notification: notify the Carrier within 48 hours of patient admission to a rehabilitation hospital or skilled nursing facility.
- Home health notification: notify the Carrier within 48 hours of the first home health visit.
- Carriers may perform concurrent and retrospective reviews after admission or after home health care has begun.
Statutory and Triggering Definitions
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