COVID-19 Testing and Treatment: Out-of-Network Coverage (Substantive)

Mike DeWine, Governor Jon Husted, Lt. Governor Jillian Froment, Director

BULLETIN 2020-05

COVID-19 TESTING AND TREATMENT: OUT-OF-NETWORK COVERAGE

Effective March 20, 2020

This Bulletin pertains 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 the State of Ohio, or that are subject to the jurisdiction of the Superintendent of Insurance (collectively, Insurers), that reimburse the costs of health care services under a health benefit plan in Ohio.

On March 9, 2020, Governor Mike DeWine declared a state of emergency in Ohio to protect the well-being of Ohioans from the dangerous effects of COVID-19, and directed state agencies to develop and implement procedures consistent with recommendations from the Department of Health designed to prevent or alleviate the public health threat. (See Executive Order 2020-01D.)

The Superintendent of Insurance (“Superintendent”) recognizes that, as part of the ongoing effort to contain and treat the COVID-19 virus, 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.

Accordingly, the Superintendent hereby orders and directs that:

1. Emergency medical conditions under Ohio law include testing and treatment related to the COVID- 19 virus. 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.

Superintendent of Insurance

Jillian Froment Director

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