Guidance for Insurers Regarding Coverage and Cost Sharing Requirements Related to COVID-19 Public Health Emergency
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State-level advisory asking North Carolina-licensed insurers to remove barriers to COVID-19 testing and treatment, adjust operations (telehealth, networks, prior authorization, formularies), and file plan changes with the Department during the declared public health emergency. Affects all insurance companies and entities licensed under Chapter 58 in North Carolina.
No material clinical or coverage changes in this revision.
Coverage Criteria and Requests
Requested and required insurer actions during COVID-19 emergency
During the declared state of emergency, insurers are requested or directed to take the following measures:
(request)
telehealth encouraged; statutory reference
(request)
(request)
filing is required; premium increase prohibited
The advisory does not list any explicit coverage exclusions. It frames coverage expectations as requests to insurers—such as waiving prior authorization and covering medically necessary COVID-19 diagnostic tests consistent with CDC guidance—rather than stating specific services or circumstances that are excluded from coverage.
Actions for Insurers and Providers
Waive prior authorization for COVID-19 tests and related services
The Department requests insurers waive prior authorization for COVID-19 diagnostic tests and covered services that are medically necessary and consistent with CDC guidance for insureds diagnosed with COVID-19.
Request for expedited formulary exceptions
Insurers are requested to make expedited formulary exceptions where appropriate, including when an insured diagnosed with COVID-19 is at serious risk or is undergoing treatment with a non‑formulary drug intended to lessen symptoms or duration; consider exceptions for formulary drug shortages.
- Expedite exceptions if the insured's condition may seriously jeopardize health, life, or ability to regain maximum function.
- Expedite exceptions for ongoing treatment with a non‑formulary drug intended to lessen symptoms or duration.
- Consider expedited exceptions when a formulary drug is in shortage.
File plan-change letter with Life & Health Division
During the declared state of emergency, insurers shall file a letter with the Department's Life & Health Division detailing any changes to their health benefit plan policies related to diagnosing or treating COVID-19; the Department will attempt to expedite review.
- Filing must be made by way of a letter to the Life & Health Division.
- The filing should detail any COVID-19–related plan changes intended to facilitate early diagnosis and treatment.
Prior authorization waiver requested for COVID-19 services
The Department requests insurers waive prior authorization for COVID-19 diagnostic tests and medically necessary covered services consistent with CDC guidance for insureds diagnosed with COVID-19; failure to do so may create access barriers (the request is not framed as a mandatory denial rule).
- Waiver applies to diagnostic tests and covered services that are medically necessary and consistent with CDC guidance.
Background and Purpose
This guidance was issued in response to the COVID-19 public health emergency and asks North Carolina–licensed insurers to remove barriers to testing and treatment during the declared state of emergency. Key operational requests include ensuring robust telehealth delivery, verifying network adequacy, waiving prior authorization for COVID-19 diagnostic tests and medically necessary services consistent with CDC guidance, and covering medically necessary diagnostic tests at no cost to the insured where consistent with CDC guidelines. The Department also requests insurers verify network capacity and consider access protections to avoid penalizing insureds under out-of-network benefit levels.
Key Definitions
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