Policy options for states to address COVID-19

The AMA has been working with state and national medical specialty societies to ensure patient access to care and increase protections for physicians during the COVID-19 pandemic. AMA provides a number of policy recommendations and options for state legislators and regulators to consider as they work to address access and coverage issues.

• Prohibit cost-sharing (co-pays, co-insurance, deductibles) for diagnostic testing (labs) and cost-sharing related to testing including hospital, emergency department, urgent care and provider office visits.
• Prohibit prior authorization for testing and all services related to testing.
• Ensure coverage for testing and related services regardless of network status of the provider.
• Ensure adoption of above policy changes to all plans including high deductible plans, short-term limited duration insurance (STLDI) plans, association health plans (AHPs) and Medicaid plans.
• Require communication to all contracted providers, pharmacies and enrollees of these policy changes.

Treatment for symptoms of COVID-19 

• Suspend any prior authorization requirements that apply to treatment and care related to COVID-19.
• Ensure coverage for the cost of care related to COVID-19 or potential COVID-19 cases without regard to the network status of provider, including no retroactive denials for care, regardless of diagnosis.
• For high deductible plans, cover the cost of care as if deductible has already been met.
• Prevent AHPs, STLDI plans, and non-regulated plans from canceling coverage or refusing to renew coverage based on an enrollee’s COVID-19 status.

Telemedicine (Medicaid and private payer) 

As part of the efforts to address COVID-19, CMS has taken steps to broaden access to telemedicine, expanding coverage and making sure telemedicine services are paid at in person rate. At a minimum we would suggest payers align with these new policies. The AMA has provided a full summary of new Medicare policies related to telemedicine.

• Ensure broad coverage and payment for all telemedicine services by all plans  and payers, including Medicaid, fully insured plans, self-insured plans, AHPs and STLDI plans.
• Temporarily allow coverage and payment for all telemedicine modalities, including voice only.
• Suspend requirements that an existing patient-physician relationship must be established prior to the provision of telemedicine services.
• telemedicine visits should be treated the same as in-person visits and should be paid at the same rate as an in-person visit.
• Provide coverage and payment of COVID-19-related telemedicine services with no cost-sharing (co-pays, co-insurance, deductibles).
• Suspend any restrictions on telemedicine, including types of services, originating sites and geographic limitations for telemedicine services.
• Suspend annual limits imposed on telemedicine services.
• If not already covered, temporarily expand physician’s medical liability coverage to include telemedicine.
• Ensure patients have access to telemedicine from the physician of their choice, if that physician makes it available. Allow physicians to provide telemedicine services directly to their patients, without requiring they contract with a specific telemedicine service.

Access to medications

• Waive time restrictions on prescription refills and authorize payment to pharmacies for up to a 30-day supply of any prescription, regardless of the date upon which the prescription medication had most recently been filled by a pharmacist. The prescriber should be notified of any refills within 72 hours.
• In the event of a shortage of any drug, waive prior authorization/step therapy if the prescribing provider recommends the patient take a different drug to treat the condition.
• Make expedited formulary exceptions if a patient is suffering from condition that may jeopardize their health, life or ability to regain maximum function or if the patient is undergoing a current course of treatment using a non-formulary drug.
• Allow enrollees the use of out-of-network pharmacies at the in-network benefit level in the event a shortage of medication occurs at network pharmacies.
• Remove restrictions on the Medicaid preferred drug lists to help avoid medication shortages. This includes ensuring coverage for methadone for Opioid Treatment Programs.
• Waive any state requirements for electronic prescribing of controlled substances (EPCS) during the period of a state or national emergency declaration for COVID-19.
• Board of Pharmacy and other actions relating to COVID19 prescribing (PDF, updated April 27, 2020)

Expanding Medicaid coverage 

• Expand Medicaid eligibility to 133 percent FPL if state has not yet opted into Medicaid expansion.
• Expand Medicaid eligibility temporarily to any uninsured state resident with COVID-19 related diagnoses or symptoms.
• Conduct outreach to uninsured populations, simplify enrollment and renewal processes, and expand 12-month continuous eligibility.
• Expand presumptive eligibility and promote 90-day retroactive eligibility.
• Suspend Medicaid work requirements and other barriers that disrupt coverage.
• Seek enhanced federal matching funds for emergency coverage options.
• Expand optional benefits and amount, duration and scope standards.
• Temporarily suspend disenrollment for the duration of the emergency.

Expanding access to coverage

• Establish special enrollment periods (including for people who currently don’t have health insurance, have recently lost health insurance or will soon lose it).
• Prevent plans from increasing premiums based on a group’s decreased enrollment or participation due to COVID-19.
• Require insurers to permit employers to continue coverage for employees under group policies even if employee would others be ineligible due to decrease in hours worked.
• Establish grace periods and other continuity of coverage policies that relieve patients and physicians of financial risk associated with delayed payment or nonpayment of premiums.

Prior authorizations and other administrative barriers

• Suspend barriers to care, including prior authorizations, to ensure there are no delays in care, patients are able to obtain medications easily and quickly, and to ensure rapid transfers from hospitals to less intensive settings.
• Ensure that prior authorizations for delayed surgeries and procedures remain valid until rescheduled.
• Extend timely filing deadlines for Medicaid and commercial payer claims.

• Cover the costs of vaccinations with no cost-sharing (co-pays, co-insurance, deductibles) and apply to all plans including high deductible plans and short-term limited durations plans.
• Communicate above policy to all contracted providers and enrollees.

• Verify that networks are adequate to handle the increase in need for health care services, including offering access to out-of-network services where appropriate and at the in-network cost-sharing level.
• Prior authorization on emergency care is prohibited regardless of whether the care is in- or out-of-network.
• Plans, at least, must comply with existing utilization review timeframes for approving requests for urgent and non-urgent care.

• Temporarily allow physicians licensed in good standing to practice across state lines. (Note: If considering broad language to include reciprocity for all health care professionals, include language clarifying that health care professionals are subject to the scope of practice laws of the host state and may not exceed the scope of practice established by their home state). See CMS guidance on state licensure of physicians providing care to Medicare patients (PDF).
• Temporarily allow states to mobilize inactive physicians into the workforce, including physicians who temporarily left for family reasons, retired physicians, and non-clinical physicians. The physician’s current or previous license must be in good standing.

• Ensure that credentialing of “new” physicians (including those physicians coming out of retirement or transitioning from inactive status and those moving to facilities in need) is expedited such that the credentialing process does not in any way delay or hinder the physicians’ provision of patient care.

• Volunteer physicians who are not otherwise covered by the workers’ compensation laws of the state may be deemed an employee of the state for purposes of making a claim under the state’s workers’ compensation system.

• Provide immunity from civil liability for any harm caused by volunteer physicians acting in good faith for care provided in response to COVID-19.
• Provide physicians immunity from civil liability for harm caused in the course of providing medical services in support of the state’s response to the COVID-19 outbreak.
• Provide physicians immunity from civil liability for harm caused resulting from a federal, state or local directive to cancel, delay or deny care as a result of the COVID-19 pandemic.

• Payers’ systems and those of network providers need to be able to bill and process the new COVID-19 billing codes.
• Insurers should submit their plans to meet these requirements to their state department of insurance.
• Streamline and simplify provider enrollment in Medicaid.
• Issue statewide stay-at-home order to close non-essential businesses, limit non-essential activities and prohibit large gatherings