This week has certainly been abuzz with news and activity related to COVID-19. In light of all the new changes, we wanted highlight the passage of CA Senate Bill 510.
This bill effectively mandates that CA based fully-insured health policies must cover all COVID-19 diagnostic and screening testing and vaccinations without cost-sharing or prior authorization requirements. The bill is retroactive to March 4, 2020.
Previously, federal law required group health plans to cover COVID-testing when ordered by a licensed or authorized healthcare provider. Federal guidance was released to make clear that the group health plan cannot impose medical screening or management criteria; however, the test must have been ordered by a licensed or authorized healthcare provider.
In practice, what we saw happen is that private testing was widely done via authorized personnel connected to a doctor on staff. This, by and large, met the requirements of federal law to ensure the group health plan did not impose member cost-sharing.
The CA specific bill further enforces and expands this notion. CA SB 510 requires group health plans to cover screening testing, which could include the costs of testing for employment purposes if requested by a member.
What is it? A new law that requires CA group health or disability insurance policies that provide coverage for hospital, medical, or surgical benefits to cover all COVID-19 diagnostic and screening testing and vaccinations approved or granted emergency use authorization by the FDA without cost-sharing or other utilization management requirements. This is regardless of whether the service is provided by an in-network or out-of-network provider.
For out-of-network test providers, the provider must accept the insurer’s payment in full and should not balance bill the member, provided that the insurer’s payment meets specific criteria.
CA SB 510 contains language that makes it so coverage for testing and vaccination for future pandemics is included as well.
When is this effective? The law is retroactive to March 4, 2020. For future coverage, the effective date is 15 business days after the date on which the United States Preventive Task Force (USPTF) or CDC makes a recommendation.
Note: Group health plans must implement the provisions of the bill beginning on January 1, 2022.
Does this mean members will be refunded any out-of-pocket costs incurred from March 4, 2020 to present? This is not entirely clear. We have contacted several insurers who are still working to interpret the new law.
When does it expire? An expiration date only applies to out-of-network coverage, and this coverage expires once the federal public emergency is declared over.
Who must comply? Group health or disability (that provide coverage for hospital, medical, or surgical benefits) plans that are subject to CA state laws which generally includes all fully-insured plans written in the state of CA.
Contact your carrier or benefits broker for more information with specific questions and concerns including treatment of retroactive claims back to March 4, 2020.
The CA Department of Managed Health Care (DMHC) previously had provided a flyer aimed at “health plan enrollees”. You can find the flyer here. While the flyer was created in March of 2021, CA SB 510 reinforces the message contained therein.
Written by: Michelle Cammayo
IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information.
This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.