During this public health emergency, new federal laws (HR 6201, HR 748) are making significant steps to eliminate consumer cost-sharing for coronavirus (COVID-19) testing, diagnosis, and prevention while states are working to increase insurance access and surprise billing protections.
The recently passed Families First Coronavirus Response Act includes several provisions that expand the ability of Medicaid and the Children’s Health Insurance Program (CHIP) to cover COVID-19 testing and testing-related services with no out-of-pocket cost to consumers. The law also includes an option allowing states to extend Medicaid coverage to uninsured individuals for testing and testing-related services. States’ medical and administrative costs for this will be fully matched by the federal government.
However, high costs associated with medical treatment pose significant challenges for the millions of uninsured and underinsured individuals across the country, and these measures may not protect Americans from costs associated with treatment and management of the virus, including prescription drugs, physicians’ visits, hospitalizations, and specialty care. Consumers need health coverage to ensure there is no barrier to receiving the care they may need.
As the pandemic worsens, state agencies are taking action to maximize access to coverage, including private insurance, as one means to protect consumers from the severe financial burden that may result from necessary medical care. This includes increasing access to qualified health plans (QHPs) sold through the health insurance marketplaces. Under requirements set by the Affordable Care Act (ACA), QHPs must cover essential health benefits, including emergency room services, hospitalizations, prescription drugs, preventive services, and mental health services critical to combatting and managing the outbreak. QHPs also must follow cost-sharing restrictions, including the provision of preventive services at no out-of-pocket cost, and the prohibition on annual and lifetime limits on spending.
State-based marketplaces (SBMs) are working diligently to leverage available flexibilities to ensure that consumers in their states are able to enroll in and maintain QHP coverage. Eleven SBMs have opted to open temporary special enrollment periods (SEPs) so uninsured individuals can apply for coverage. This is in addition to actions taken by all SBMs to promote other SEPs available to consumers, including an SEP trigged by loss of minimum essential coverage (such as employer-sponsored coverage).
SBMs are rapidly tweaking tools, outreach strategies, and operations to ensure optimal customer service while also taking steps to comply with physical distancing guidance issued by state public health officials. DC Health Link, in Washington, DC, has created a table to educate consumers about how COVID-19-related services are covered under their health plans. Nevada Health Link has provided a comprehensive listing of state and federal resources available to consumers. Several SBMs are also coordinating closely with insurers who can leverage payment and grace period deadline extensions to help ensure consumer coverage is not disrupted during the pandemic.
In addition to increasing access to coverage, states are also moving forward to enact protections against the practice of surprise balance bills, or unexpected medical bills usually received because an enrollee unknowingly received out-of-network care. Surprise billing laws foremost seek to protect consumers from paying extreme bills incurred when they receive out-of-network services either unknowingly or because there was no other choice of provider or facility. Surprise billing protections will be even more important to ensure that consumers are protected from unprecedented costs in the event they require COVID-19 treatment.
Health systems are rapidly changing in response to the pandemic – states are setting up make-shift clinics, expanding telehealth services, authorizing more providers to be reimbursed for services, and relaxing provider licensing requirements. Many of these actions are necessary to increase provider capacity to meet the rapidly accelerating need for emergency health care services. However, insurers typically operate by only covering care administered by a limited network of providers. And, in some cases, insurers may include a facility, such as a hospital, in their network, but not actually cover all the providers who work there or services performed at that facility — including specialists or laboratory services. Even in normal circumstances, these situations leave insured individuals vulnerable to surprise medical bills. As states rush to expand health care capacity and consumers have increased urgency to seek care, consumers are increasingly susceptible to receiving care from an out-of-network provider or at an out-of-network facility.
Under the ACA, insurers are required to cover out-of-network emergency services as if delivered in-network. That same protections does not extend outside of an emergency setting, though several states have passed laws to protect consumers from surprise bills, including those incurred when a consumer had no other choice of where to receive treatment.
Recently, on March 18, 2020, Maine took emergency action to enact LD 2105, which incorporated surprise billing protections in the case of emergency services into state law. The law also includes billing protections for uninsured individuals as well as those covered by self-insured plans.
In Virginia, SB 172 has been sent to the governor. Like Maine’s law, the bill incorporates protections in the event of emergency care into state law. The bill also adds new protections in the case of out-of-network surgical or ancillary services provided at an in-network facility.
Without additional federal action, states will continue to take the lead in doing what is best for their citizens, including finding innovative strategies to ensure individuals have the best possible access to available services, while also protecting them from undue financial strain. The National Academy for State Health Policy will continue to monitor and report on the situation as it evolves.