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COVID-19: Frequently Asked Questions

Below are some of the most frequently asked questions CMA has received during the COVID-19 outbreak. By default, the most recent answers will appear up top. You can also filter the FAQ by category. We will update this resource regularly.

More questions? Email communications@cmadocs.org.


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Is there any patient cost-sharing for COVID-19 related testing and screening?

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The rules differ depending on the patient’s health plan/insurance product the patient. Medicare, self-funded plans, and PPOs regulated by the California Department of Insurance fall under federal guidance, which requires the following:

  • Required to waive patient cost sharing for COVID-19 testing and screening. 
  • Responsible for payment of the waived cost sharing to providers for applicable services. They may not deduct the cost sharing that must be waived out of the provider’s payments. 
  • Prohibited from imposing prior authorization requirements for COIVD-19 testing and screening. 
  • Required to cover COVID-19 diagnostic testing regardless of network status. 

HMOs and PPO products regulated by the Department of Managed Health Care (DMHC) fall under the department’s emergency regulations on COVID-19 testing. The regulations create a rigid three-tiered testing prioritization structure as follows:

  • Tier 1 –Individuals who are symptomatic or those with known or suspected recent exposure are covered under federal law, which prohibits payors from imposing cost-sharing, prior authorization or other medical management requirements. Federal law also requires payors to reimburse any provider of COVID-19 diagnostic testing, regardless of network status.
  • Tier 2 – This tier applies to individuals the DMHC emergency regulations define as “essential workers.” The regulations deem COVID-19 testing as a medically necessary basic health care service and prohibits plans from requiring prior authorization. However, under tier 2 payors are allowed to charge cost sharing and individuals are required to obtain testing from an in-network provider as a condition of benefits.
  • Tier 3 – This tier applies to individuals that are not included in tier 1 or tier 2 – those who are asymptomatic, have not had any known exposure and are not defined as essential workers under the emergency regulations. For patients in this tier, the regulations allow payors to charge cost-sharing, require in-network testing as a condition of benefits and allow prior authorization requirements. Additionally, in order to determine whether a prior authorization is required, the regulations place the burden on the physician to determine whether the individual is an essential worker and does not provide guidance on how to report that to the payor.

View CMA’s article on DMHC’s emergency regulations

| Categories: Outdated, Testing, Practice Management | Return

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