COVID-19 Update: ODI issues bulletin on out-of-network coverage for coronavirus testing and treatment

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On March 20, 2020, the Ohio Department of Insurance (ODI) issued Bulletin 2020-05, which contains the order of the Superintendent of Insurance regarding preauthorization and cost-sharing requirements for testing and treatments relating to COVID-19 (coronavirus).

The order applies to all health plan issuers, including insurance companies, health insuring corporations, MEWAs, non-federal governmental health plans and other entities transacting the business of insurance in Ohio, or that are subject to the jurisdiction of the superintendent (collectively, insurers) that reimburse the costs of health care services under a health benefit plan in Ohio.

In the bulletin, the superintendent first explained that "testing and treatment for COVID-19 may be geographically regionalized – meaning, testing and treatment will be provided by designated hospitals throughout the state. While many Insurers have network agreements with these hospitals, there may be some cases where an insured is directed to a hospital for treatment and testing that is out-of-network under their health plan’s coverage.”

The superintendent ordered the following:

  1. Emergency medical conditions under Ohio law include testing and treatment related to COVID-19. These emergency services must be covered without preauthorization and must be covered at the same cost-sharing level as if provided in-network. COVID-19 testing and treatment are necessarily emergency services, because symptoms of COVID-19 would result in a prudent layperson with an average knowledge of health and medicine to reasonably expect the lack of medical attention to result in serious harm.
  2. As a result, insurers must cover emergency medical conditions in accordance with applicable law. Insurers must provide benefits with respect to an emergency service in an amount at least equal to the greatest of the amount negotiated with in-network providers, the amount calculated using the same method the plan generally uses to determine payments for out-of-network services or the amount that would be paid under Medicare. Additionally, health insuring corporations providing coverage in Ohio must ensure coverage for out-of-network emergency services without balance billing.

[View source.]

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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