Claim pend/processing during premium delinquency

If a health insurance issuer pends claims because an insured is delinquent on premium payments, providers must be aware that the issuer will notify them of the possibility of denied claims during the insured’s grace period. If the issuer receives the delinquent premium payment during the grace period, all pending claims for the applicable time period must be processed and adjudicated, and providers must be notified that the claims are no longer pending. However, after the first month of the grace period has lapsed, the issuer may deny payment on pended claims for services rendered during the nonpayment period if it is subsequently entitled to cancel or terminate the policy.

• Issuers shall notify providers of the possibility for denied claims when an insured is in the grace period (§4919.C).
• Upon receipt of delinquent premium during the grace period, all pending claims for the time period to which such payment applies shall be processed and adjudicated and the provider notified (§4919.D).
• After the first month of the grace period, an issuer may deny payment on pended claims for services rendered during the period of nonpayment if entitled to cancel or terminate the policy (§4921.A).

Waive telemedicine network and prior‑relationship restrictions

Health insurance issuers must waive telemedicine access restrictions during the emergency: they shall waive coverage limitations restricting telemedicine to in‑network telemedicine providers and waive any requirement that patient and provider have a prior relationship. Telemedicine consultations between a patient and a provider must be covered to the extent the same services would be covered if provided in person, and mental health telemedicine shall be covered to the same extent as in‑person mental health services where appropriate.

• Waive coverage limitations restricting telemedicine access to providers in the plan’s telemedicine network (§4935.A).
• Waive any requirement that the patient and provider have a prior relationship (§4935.B).
• Cover patient–provider telemedicine consultations to the extent the same services would be covered in person and cover mental health telemedicine similarly (§4935.C–D).

Allow early/additional refills and waive pharmacy network restrictions

Health insurance issuers shall allow insured individuals to obtain prescription refills even if recently filled, consistent with approval from the patient’s health care provider and/or pharmacist; this does not apply to high‑abuse drugs restricted to 7‑day prescriptions. Mail‑order replacement prescriptions may be mailed to an alternate address if requested by the insured. Issuers must also waive any restrictions on out‑of‑network pharmacy access.

• Allow refills even if the prescription was recently filled, with provider/pharmacist approval; excludes high‑abuse drugs restricted to 7‑day supplies (§4933.A).
• Suspend provisions restricting replacement mail‑order prescriptions and permit mailing to an alternate address upon insured request (§4933.B).
• Waive any restrictions on out‑of‑network pharmacy access to services or prescriptions (§4933.C).

Handling of pended claims and provider notifications during premium delinquency

Consolidating the pended‑claim rules: issuers may pend health claims during an insured’s premium delinquency; providers should expect notification of potential denials during the grace period. If the delinquent premium is paid within the grace period, issuers must process and adjudicate all pending claims for the covered time period and notify providers that claims are being processed. If the policy becomes cancellable and the first month of the grace period has passed, issuers may deny pended claims for services rendered during the nonpayment period.

• Claims notification procedures are suspended broadly, but issuers must still notify providers of possible denied claims when an insured is in the grace period (§4913; §4919.C).
• Pending claims must be processed upon receipt of delinquent premium and timely‑payment requirements are reinstated as of the premium payment date (§4919.D).
• After the first month of the grace period, issuers may deny pending claims if they are entitled to cancel or terminate the policy for nonpayment (§4921.A).