As COVID-19 diagnoses grow, states are making rapid-fire adjustments so consumers can access the care they need. One key strategy has been promoting health insurance enrollment to protect consumers from potentially exorbitant medical bills. Recognizing more protection is needed, state insurance regulators are also making sure consumers maintain their coverage, find appropriate care, and are protected from exorbitant or surprise medical bills.
Enabling Continuity of Coverage, despite Life Disruptions
Maintenance of health insurance coverage will be a challenge for many, especially for the recently unemployed who face sudden income uncertainty or even loss of employer-provided health insurance. Several states are mandating or requesting that insurers refrain from terminating health plans. While some states define specific conditions under which carriers must suspend terminations – for example, Arkansas prohibits terminations in the case of job loss or COVID-19 diagnosis – others, including Colorado, Indiana, and Maine, apply broadly in the case of non-payment of premiums during the public health emergency.
These policies do not absolve consumers of their responsibility to pay their premiums, but rather grant a needed reprieve (usually up to 60 days) during which consumers are required to contact their insurers to figure out a payment strategy. Several states also recommend that insurers consider waving any late fees or penalties for non- or late payment, recognizing that additional fees put undue burden on already strained households.
States are also working to provide flexibility to businesses to help them retain their ability to offer coverage during lean times. Such flexibilities include waiving minimum participation rates, eliminating “hours worked” and minimum contribution requirements, and opening enrollment to individuals who may have declined coverage during a company’s typical open enrollment period.
Directing Consumers to Appropriate Care and Services
As health systems become increasingly strained, it is more important that ever to ensure that consumers are directed to the most appropriate care settings. Health insurers have a direct communication channel to their enrollees and serve an important role in helping direct consumers to care. Most states have requested insurers to help keep consumers properly informed during the pandemic. Such measures include posting updated information about COVID-19 on insurer websites, establishing robust communication channels so insurers can rapidly respond to consumer inquiries, and expanding nurse help-lines to aid in triaging care.
Encouraging Remote Care via Telehealth
Both state and federal leaders have recognized the importance of telehealth to help mitigate the spread COVID-19 by enabling consumers to solicit services from home, regulators can enable immediate self-quarantine of individuals suspected of infection, while also helping preventing needless exposure for those at risk of infection. States are recommending that insurers bolster their available telehealth workforce, including staff available to handle behavioral health services. While some states already enforce parity laws for telehealth delivery, meaning that telehealth services are reimbursed at the same rate as in-person services, some states are newly requiring parity for telehealth, if only for the limited duration of this public health emergency.
To ease widespread implementation of telehealth services, the Department of Health and Human Services Office of Civil Rights (OCR) has temporarily relaxed privacy and security requirements to enable widespread access to telehealth tools during this emergency. In tandem, states have enacted or recommended policies to bolster insurer capacity to offer telehealth services. These include suggestions for how insurers could relax restrictions that normally prohibit utilization of telehealth including:
- Waiving requirements for an in-person consultation prior to rendering of telehealth services;
- Allowing services to be delivered straight to a consumers’ homes (versus a certified point of care); and
- Removing prohibitions on the use of common technologies, such as FaceTime, Skype, or telephone (without video), which are normally restricted due to privacy concerns.
Several states, including Connecticut, Delaware, and Iowa, are also encouraging insurers to offer telehealth services at reduced or zero-dollar cost sharing to further incentivize consumers to use telehealth services. Massachusetts has mandated telehealth coverage for COVID-19 related services with no cost-sharing.
Expediting Access to Necessary Services
Insurers and providers have established processes used to assess if an enrollee is receiving appropriate, covered services to treat an illness. These processes include pre-authorization requirements and utilization reviews that are conducted before a service is performed. However, these checks can impose administrative burdens and affect the timeliness of care, which together adds additional strain to health care providers. Several states have existing laws that put time limits on approvals to help expedite services, however, under the current state of emergency many are recommending that insurers waive or suspend use of these tools (e.g., prior authorizations, utilization review). For example, Colorado and Georgia explicitly call for elimination of pre-authorization requirements to transition patients to in-home or acute care settings, which would help maneuver patients out of limited hospital beds to alternative care settings. Such changes will help expedite care and alleviate strained administrative systems, which, in turn, allows systems to better serve patients.
Protecting Patients from High Medical Bills
Recognizing that even the insured are likely to face some medical costs related to COVID-19, states led the way in issuing guidance to recommend that insurers cover testing without cost sharing for consumers. The federal government followed by enacting the Families First Coronavirus Response Act that requires insurers to cover testing for COVID-19, but concerns remain that consumers may be billed for COVID-19-related treatment. A few states, including Massachusetts and New Mexico, have mandated coverage of COVID-19 treatment and others, including Florida, Georgia, and Kansas, have requested that insurers consider such steps. Several major insurers have stepped forward and announced they will cover COVID-19 treatments at low-to-no cost, even without a mandate. However, variation exists over what kind of treatments will be covered and how care delivery settings may affect coverage.
As discussed in the recent National Academy for State Health Policy (NASHP) blog, States Act to Increase Medicaid/Marketplace Coverage to Insulate Consumers from COVID-19 Care Costs, rapid evolution of health care settings and limitations on available workforces put consumers at particular risk to receive care out-of-network, which could lead to surprise medical or balance bills. For example, hospitals and new makeshift facilities are bringing in new providers to address surplus demand, but new providers may serve as contractors, in which case they may not technically be considered part of a hospital’s network. States have put forth a number of solutions to mitigate these issues – ranging from urging carriers to review and modify networks to meet increased demand to clear mandates that insurers cover out-of-network providers at in-network rates if conditions make it difficult to seek in-network care.
Massachusetts has enacted some of the strictest consumer protections, mandating in-network coverage of acute care services related to COVID-19 treatment and prohibiting providers from balancing billing consumers for the cost of out-of –network services. Massachusetts also specifies reimbursement rates for services delivered by out-of-network providers – the in-network rate when the insurer has a an existing agreement with the hospital at which the provider is practicing, and 135 percent of the Medicare rate if no such agreement exists.
Collectively, these changes will help protect consumers during this extraordinary time. However, as this crisis continues, these policies could have significant long-term ramifications for insurance markets as insurers absorb the new costs related to these mandates. NASHP will continue to monitor these changes, including long-term impact.