In our previous Bolton blog and Alert, we outlined how the end of the PHE will affect group health plans. In other words, what could change with regards to coverage of COVID-19 diagnosis, testing and other related services. This article focuses on certain CA specific laws that affect CA fully insured group health plans.
The passage of two CA specific laws extend no cost sharing provisions for CA based insured group health plan:
CA Senate Bill (SB) 510:
- Requires CA based fully insured health plans to cover COVID-19 diagnostic and screening tests without cost-sharing or other utilization management requirements for both in and out of network providers.
- The out-of-network requirement expires in mid-November (which was extended to six months after the end of the PHE, per the recently passed SB 1473 below); however, the in-network requirement will remain.
CA Senate Bill 1473:
- Requires group health plans to cover therapeutics for the treatment of COVID-19 without cost sharing, utilization management, or in-network requirements.
- This becomes effective for health plans issued or renewed on or after 9/25/22.
- The out-of-network coverage will end six months after the end of the PHE.
- Beginning six months after the PHE ends, group health plans will no longer be required to cover the cost sharing for COVID-19 diagnosis, testing and other related services when delivered by an out-of-network provider.
Let’s say that in reverse: Coverage for the above will continue to be provided at no member cost share by both in- and out-of-network providers for the six months following the end of the PHE. At the end of the six months, in-network coverage for these services will continue at no member cost share; however, out-of-network coverage can and will likely be limited.
- The CA Department of Managed Health Care (DMHC) may also require carriers to issue notices to enrollees with regards to the end of the PHE.
What does this mean for an employer’s group health plan?
For self-insured group health plans, only federal law applies, which means the requirement for group health plans to cover COVID-19 tests without cost sharing, both for OTC and laboratory tests, will end with the PHE. Although, the COVID-19 vaccine must be covered with no cost sharing when administered by an in-network provider.
Additionally, there is no requirement to cover treatment (therapeutic or otherwise) of COVID-19 any differently than any other type of medical condition.
For CA based fully insured group health plans, CA SB 510 means that carriers will have to continue to cover COVID-19 diagnostic and screening tests without cost-sharing or other utilization management requirements. Further, CA SB 1473 means that carriers must cover therapeutics as well. At the end of six months after the PHE, carriers will only be obligated to cover the cost share of these services in-network.
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