The Office of the Commissioner of Insurance (OCI) is issuing this Bulletin to assist individuals and entities regulated by OCI regarding the provision of insurance-related services during this urgent Coronavirus (COVID-19) public health challenge. In order to protect the public health, insurers, self-funded plans, pharmacy benefit managers and cooperative health plans (collectively, Health Plan Issuers) are requested to identify and remove barriers to testing and treatment for COVID-19. OCI requests Health Plan Issuers that offer health care plans to Wisconsin residents to take the following immediate measures related to the potential impact of COVID-19.
Preparedness. Health Plan Issuers should review their internal processes and operations to ensure that they are prepared to address COVID-19 cases in Wisconsin, including by providing insureds with information and timely access to all medically necessary covered health care services. As the COVID-19 situation continues to evolve, Health Plan Issuers should continually assess their readiness and make any necessary adjustments.
Information Access. Access to accurate information and avoiding misinformation are critical. Therefore, OCI requests Health Plan Issuers to inform insureds of available benefits, quickly respond to insured inquiries, and consider revisions needed to streamline responses and benefits for insureds. Health Plan Issuers should make all necessary and useful information available on their websites and staff their nurse-help lines accordingly. Useful links may include a link to the Wisconsin Department of Health Services information regarding COVID-19 at
https://www.dhs.wisconsin.gov/disease/covid-19.htm or to the Centers for Medicare and Medicaid at
https://www.cms.gov/newsroom/press-releases/cms-prepares-nations-healthcare-facilities-coronavirus-threat. Health Plan Issuers are encouraged to promptly notify providers, nurse-help line staff and customer service personnel on the Health Plan Issuer's policies regarding COVID-19.
Testing for COVID-19. OCI requests Health Plan Issuers waive any cost-sharing for COVID-19 laboratory and radiology tests so that cost-sharing is not a barrier for access to this important testing. In addition, Health Plan Issuers are also requested to waive the cost-sharing for a provider office visit, urgent care center visit, hospital visit and an emergency room visit when the basis for the visit is related to testing for COVID-19.
Telehealth Delivery of Services. Given that COVID-19 is a communicable disease, some insureds may be using telehealth services, if offered, instead of in-person health care services. Health Plan Issuers are reminded to review provisions in current policies regarding the delivery of health care services via telehealth and ensure their telehealth programs with participating providers are robust and will be able to meet any increased demand.
Network Adequacy and Access to Out-of-Network Services. Health Plan Issuers are requested to verify their provider networks are adequate to handle a potential increase in the need for health care services in the event more COVID-19 cases are diagnosed in Wisconsin. If a health plan does not have a health care provider in its network with the appropriate training and experience to meet the particular health care needs of an insured, or does not have a sufficient number of available health care providers to meet the needs of the insureds, Health Plan Issuers are requested to develop a plan, including making exceptions to provide access to an out-of-network provider at the in-network cost-sharing level.
Prior Authorization Requests. Timely decision making is essential to responding appropriately to COVID-19, and it is particularly important with respect to requests for prior authorization. Health Plan Issuers are requested to expedite prior authorization requests to the extent possible. Health Plan Issuers should not use prior authorization requirements as a barrier to access necessary treatment for COVID-19 and should be prepared to expedite grievances and appeal processes for services related to COVID-19, when medically appropriate.
Immunizations. Although a vaccine is not currently available for COVID-19, it has been reported to be in development. In the event an immunization becomes available for COVID-19, OCI requests that Health Plan Issuers immediately cover the immunization at no cost-sharing for all covered members.
Access to Prescription Drugs. Health Plan Issuers are requested, where appropriate, to make expedited formulary exceptions if the insured is suffering from a health condition that may seriously jeopardize the insured's health, life, or ability to regain maximum function or if the insured is undergoing a current course of treatment using a non-formulary prescription drug that is intended to lessen symptoms or the duration of the virus. Health Plan Issuers are also encouraged to make expedited formulary exceptions if there is a shortage of a formulary drug.
Because of the possibility of self-quarantine for infected, exposed, or at-risk individuals, OCI is requesting that Health Plan Issuers be flexible on prescription drug supply limitations and early refill limitations. Health Plan Issuers are requested to allow insureds to fill and refill prescription medications for up to a 90 day supply or until the prescription expires, if shorter. In addition, Health Plan Issuers are asked to allow for early refills without additional authorization requirements.
Information Sharing. To ensure that public health officials and the public are adequately informed about what the health insurance industry is doing in response to COVID-19, the Commissioner may request that Health Plan Issuers provide information on the steps they are taking in response to this Bulletin.
This bulletin is not to be considered OCI's interpretation of the law. Any questions concerning this bulletin may be directed to Olivia Hwang, Director of Public Affairs, at
Olivia.Hwang@wisconsin.gov.