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Coverage Rules Following the End of the Public Health Emergency in California

California state laws add six months to the federal Public Health Emergency (PHE) requirements on health plans to continue covering COVID-19 tests, vaccines and treatment from any licensed provider (in- or out-of-network) with no prior authorization or enrollee cost sharing. The federal PHE ended on May 11, 2023, and state laws extend these requirements for six months through November 11, 2023.

After November 11, 2023, enrollees can continue to access COVID-19 tests, vaccines and treatment with no prior authorization or cost sharing when they access these services through their health plan’s network. Health plan enrollees can be charged cost-sharing only if these services are provided out of network after November 11, 2023.

CARRIER COVERAGE AFTER NOVEMBER 11, 2023 RESOURCES
Aetna In-network coverage for the following services will continue at no member cost-share, however member cost-share may be applied based on a member’s out-of-network plan benefits: vaccines, COVID-19 anti-viral medications or treatments (like Paxlovid).

Standard member cost-share will apply for lab tests, telemedicine, urgent care, emergency room, and office visits associated with COVID testing.

OTC COVID tests will no longer be covered.
  • Announcement
  • Aetna COVID Resources
Anthem Blue Cross Standard member cost-share will apply for out of network services including testing and therapeutics.
  • Announcement
  • End of PHE Details
  • Anthem COVID Resources
Blue Shield of California Member cost-share will continue to be waived for in-network diagnostic testing, vaccines, and therapeutics. After November 11, 2023, cost-share for out-of-network COVID-19 services will no longer be waived for most plans and member cost-share may be applied based on a member’s out-of-network plan benefits.

Members can continue to submit a request for reimbursement for up to 8 at-home COVID-19 tests per month.

Coverage for treatments other than therapeutics is based on an individual’s standard in- or out-of-network benefits, which is not impacted by either the end of the PHE or six-month extension period.
  • Announcement
  • Blue Shield PHE Page
CaliforniaChoice Members should refer to their enrolled health plan. -
Cigna + Oscar

Lab tests, including PCR and rapid antigen, and treatment will be will be covered in-network at the standard plan deductible and cost-share. Over-the-counter tests will continue to be covered .

  • Announcement
  • C+O COVID Resources
Covered California for Small Business Members should refer to their enrolled health plan. -
Health Net NG PPO and HDHP/HSA Plans
What's Changing
  • COVID-19 vaccines, testing, and therapeutics received from an out-of-network provider will be subject to plan benefits. No prior approval required. (HDHP/HSA plans must meet the plan deductible before coverage begins)
  • Over the counter (OTC) COVID-19 Test kits purchased at an out-of-network pharmacy are subject to lab office visit copay. A medical claim form will need to be submitted.(HDHP/HSA plans must meet the plan deductible before coverage begins)
What's Not Changing
  • COVID-19 vaccines, testing, and therapeutics received from an in-network provider remain at no cost. No prior approval required.
  • OTC COVID-19 Test kits are at no cost if using one of Health Net’s in-network retail pharmacies.

NG HMO Plans
No changes are being made at this time.

  • Announcement
  • Health Net COVID Resources
Kaiser Permanente® Details will be shared at a later date.
  • Announcement
  • Kaiser COVID Resources
MediExcel Health Plan Not announced.
  • MediExcel COVID Resources
Sharp Health Plan Not announced.
  • Sharp COVID Resources
Sutter Health Plus No changes will be made through December 31, 2023.

Beginning January 1, 2024 for new and renewing plans:
  • OON testing, including related provider services, will be covered at standard benefit cost sharing. Cost sharing will apply based on where the services are received.
  • Over-the-counter tests purchased without a prescription at an out-of-network non-participating pharmacy will be limited to eight tests per member per month, reimbursed up to $12 per test.
  • Out-of-network treatment for a confirmed diagnosis of COVID-19 will be only covered if it is provided at an urgent care location or emergency department. These services will have the standard urgent care or emergency services cost share based on place of service.

Sutter will continue to cover COVID-19 immunizations, prescription drugs and therapeutics at no cost share when delivered by in-network or out-of-network providers.

  • Announcement
  • Sutter COVID Resources
UnitedHealthcare In-network coverage for vaccines will continue at no member cost-share, however member cost-share may be applied based on a member’s out-of-network plan benefits. Lab tests, treatment, telehealth, and virtual visits will be covered at the members standard plan benefits. OTC COVID tests will no longer be covered.
  • Announcement
  • Frequently Asked Questions
  • UHC COVID Resources
Western Health Advantage Details will be shared at a later date.
  • Announcement
  • WHA COVID Resources

 

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