California Department of Managed Health Care All Plan Letters mid-year 2022 and 2021

The California Department of Managed Health Care has issued a number of All Plan Letters (APLs) to date addressing California legislation that went into effect in calendar years 2022 and 2021.  Anthem Blue Cross (Anthem) is summarizing certain key parts of the APLs.  To see the full APLs summarized below, please click here.

APL 22-017

In our August 2022 provider newsletter, we summarized APL 22‑017 which provided guidance on how commercial health plans are expected to comply with requirements to cover COVID-19 therapeutics.  Anthem’s notification was to inform network providers that at Anthem, COVID-19 therapeutics are covered services when medically necessary to treat an enrollee.

As we stated, Anthem follows guidance issued by the federal Department of Health and Human Services, the National Institutes of Health, and the CDC regarding COVID-19 therapeutics that can be effective when administered within five to seven days of the onset of symptoms. Accordingly, Anthem considers access to COVID-19 therapeutics an urgently needed service. To ensure that enrollees for whom a COVID-19 therapeutic is medically necessary have access to these treatments and are given a treatment as soon as possible, Anthem has waived any prior authorization requirements with respect to COVID-19 therapeutics.

APL-21-025 (consolidates multiple new laws)

AB 342, Colorectal Cancer Screening and Testing, codified in Health and Safety Code § 1367.668, requires commercial health plans, on or after January 1, 2022, to cover, at zero cost-sharing, a ectal cancer screening test assigned either a grade A or B by the United States Preventative Services Task Force (USPSTF). The required colonoscopy for a positive result on a test or procedure, other than a colonoscopy, that is a ectal cancer screening examination or laboratory test identified assigned either a grade A or B by the USPSTF shall also be provided without any cost-sharing.  AB 342 allows plans that have coverage for out-of-network benefits to impose cost- sharing requirements for the items or services described in this law that are delivered by an out-of-network provider.

AB 347, Step Therapy, codified in Health and Safety Code §§ 1367.206, 1367.241 and 1367.244 requires commercial health plans, on or after January 1, 2022, to expeditiously grant a request for a step therapy exception within the applicable time limits required by Section 1367.241 if a prescribing provider (i) determines use of the prescription drug required under step therapy is inconsistent with good professional practice for the provision of medically necessary covered services, while taking into consideration the enrollee’s needs, medical history, and professional judgment and (ii) submits justification and clinical documentation supporting the provider’s determination to the plan.  This law (a) requires a plan to notify the prescribing provider within 72 hours of receipt, or within 24 hours of receipt if exigent circumstances exist, if a request for prior authorization or a step therapy exception is incomplete or additional clinical material information is necessary to make a coverage determination is needed. Once the requested information is received, the applicable time period to approve or deny a prior authorization or step therapy exception request, or to appeal, shall begin to elapse, and (b) allows enrollees to appeal to the plan through existing grievance procedures pursuant to Section 1368 and provider to appeal a denial as permitted under the plan’s existing utilization management procedures. The external exception request review process shall apply to a denial of a prior authorization or step therapy exception request.  The law also requires a plan contract delegating utilization review or utilization management functions to include terms that require the contracted entity to comply with Sections 1367.206 and 1367.241.

 

AB 457, Telehealth, codified in Health and Safety Code §§ 1374.14 and 1374.141, requires (i) commercial health plans that contract with third-party corporate telehealth providers to notify enrollees of their right to access their medical records and that the record of any services provided to the enrollee through a third-party corporate telehealth provider shall be shared with their primary care provider unless the enrollee objects, (ii) requires a plan contract delegating responsibility of the provisions of this new law to require the entity with whom the plan is contracting to comply with Section 1374.141 and (iii) requires plans to submit information regarding third-party corporate telehealth providers in the annual timely access and annual network submission.

 

AB 1184, Confidential Communication of Medical Information codified in Civil Code §§ 56.05, 56.35 and 56.107, requires health plans, on or after July 1, 2022, to protect the confidentiality of a subscriber or enrollee’s medical information, to not require a protected individual to obtain the primary subscriber or other enrollee’s authorization to receive sensitive services or submit a claim for sensitive services if the protected individual has the right to consent to care.  Also requires plans to direct certain communications regarding a protected individual’s receipt of sensitive services directly to the protected individual receiving care and requires plans to notify subscribers and enrollees that they may request a confidential communication in the following methods: (1) upon initial enrollment and annually thereafter upon renewal, (2) in the EOC, and (3) on the plan’s website.  The law also prohibits plans from disclosing medical information relating to sensitive health services provided to a protected individual to the primary subscriber or any plan enrollees other than the protected individual receiving care, absent an express written authorization of the protected individual receiving care.

 

SB 221, Timely Access, found in Health & Safety Code §§ 1367.03 and 1367.031, codifies some of the timely access standards adopted in regulation by the DMHC.  It requires, on or after July 1, 2022, that nonurgent follow-up appointments with a nonphysician mental health care or substance use disorder provider be offered within 10 business days of the prior appointment for those undergoing course of treatment for an ongoing mental health or substance use disorder condition. This language does not limit coverage for nonurgent follow-up appointments with a nonphysician mental health care or substance use disorder provider to once every 10 business days.  This law adds references to mental health and substance use disorder providers to other provisions in Section 1367.03 and requires plans to ensure they have sufficient numbers of contracted providers to maintain compliance with timely access and other requirements in Section 1367.03. This law also adds a requirement that a plan that uses a tiered network demonstrate compliance with the standards established by Section 1367.03 based on providers available at the lowest cost-sharing tier.  Importantly, this law provides that the obligation of a plan to comply with Section 1367.03 shall not be waived if the plan delegates to its medical groups, independent practice associations, or other contracting entities any services or activities that the plan is required to perform.

 

SB 242, Reimbursement For PPE, codified in Health & Safety Code § 1374.192, requires commercial health plans, on or after January 1, 2022, (i) to reimburse contracting providers for business expenses to prevent the spread of diseases causing public health emergencies, requires plans to reimburse these business expenses for each individual patient encounter, limited to one encounter per day per enrollee for the duration of the public health emergency. (ii) prohibits plan delegation of the financial risk to a contracted provider for the cost of enrollee services provided under this new law unless the parties have negotiated and agreed upon a new contract provision pursuant to Section 1375.7 and (iii) applies to public health emergencies declared on or after January 1, 2022. 

 

SB 306, Sexually Transmitted Disease: Home Testing Kits Coverage, is codified in Health and Safety Code § 1367.34.  As our reminder sent to you via email in July 2022, Senate Bill (SB) 306 requires health plans to provide coverage for home test kits for sexually transmitted diseases (STD), including the test kit and any laboratory costs of processing the kit that are deemed medically necessary or appropriate. The kit must be ordered directly by a clinician or furnished through a standing order for patient use based on clinical guidelines and individual patient health needs at zero-dollar cost share to Anthem Blue Cross members.

 

For purposes of this bill, home test kit means a product used for a test recommended by the federal Centers for Disease Control and Prevention guidelines or the United States Preventive Services Task Force that has been CLIA-waived, FDA-cleared or -approved, or developed by a laboratory in accordance with established regulations and quality standards to allow individuals to self-collect specimens for STDs, including HIV, remotely at a location outside of a clinical setting.

 

SB 368, Deductibles and Out-of-Pocket Maximums, codified in Health and Safety Code § 1367.0061, (i) requires plans, on or after July 1, 2022, to monitor an enrollee’s accrual towards their annual deductible and annual out-of-pocket maximum (OOPM) (ii) requires a plan to provide an enrollee with their accrual balance toward their annual deductible and annual OOPM for every month in which benefits were used and until the annual balance equals the full deductible amount or the full OOPM amount. In addition, a plan shall establish and maintain a system that allows an enrollee to request their most up-to-date accrual balance toward their annual deductible or annual OOPM from their plan at any time. (iii) requires accrual updates to be mailed to enrollees until the enrollee has elected to opt out of mailed notices and elected to receive the accrual update electronically, or unless the enrollee has previously opted out of mailed notices. Plans must notify enrollees of their rights pursuant to this new law, including how to request information and how to opt out of mailed notices and elect to instead receive their accrual update electronically, and (iv) requires a plan contract delegating claims payment functions to comply with the requirements of this new law with plan oversight of the delegated functions.

 

SB 428, Adverse Childhood Experiences Screenings, codified in Health and Safety Code § 1367.34, requires a plan, on or after January 1, 2022, that provides coverage for pediatric services and preventive care to additionally include coverage for adverse childhood experiences (ACEs) screenings, and allows a plan to apply cost-sharing requirements as authorized by law.

 

SB 510, COVID; Testing and Vaccination, codified in Health & Safety Code §§ 1342.2 and 1342.3, requires plans to cover the following costs without cost-sharing, prior authorization, or utilization management regardless of whether the services are provided by an in-network or out-of-network provider, (i) costs associated with diagnostic and screening testing for COVID-19; and, (ii) costs associated with the item, service or immunization that is intended to prevent or mitigate COVID-19, (ii) requires plans to cover COVID-19 diagnostic and screening tests and immunizations without cost-sharing when delivered by an out-of-network provider until the federal public health emergency expires. All other requirements remain in effect after the federal public health emergency expires. (iii) requires plans to reimburse an in-network provider, to the extent a provider would have been entitled to receive cost-sharing for these services, the amount of that lost cost-sharing through a negotiated rate or an out-of- network provider in an amount that is reasonable as set forth in this new law, and (iv) prohibits plan delegation of the financial risk to a contracted provider for diagnostic and screening testing related to the public health emergency unless the parties have negotiated and agreed upon a new contract provision pursuant to Section 1375.7.

 

SB 535, Biomarker Testing Mandate, codified in Health and Safety Code § 1367.665, prohibits plans, on or after July 1, 2022, from requiring prior authorization for biomarker testing for an enrollee with advanced or metastatic stage 3 or 4 cancer or biomarker testing for cancer progression or recurrence in the enrollee with advanced or metastatic stage 3 or 4 cancer.  This law allows a plan to require prior authorization for biomarker-testing that is not for an FDA-approved therapy for advanced or metastatic stage 3 or 4 cancer.

CABC-CM-005730-22