New-Covid-Billing-Guidelines-CA

Beyond the CARES Act: New COVID-19 Billing Guidelines for California

On October 8, 2021, Governor Gavin Newsom of California signed Senate Bill 510 into law. This law requires group health and disability insurance plans to cover all COVID-19 testing and vaccinations without cost-sharing or prior authorization requirements. The bill is retroactive to March 4, 2020, and sets the stage for testing and vaccination coverage in California during future pandemics.

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Coverage Provided

The law specifically provides coverage for:

  • Vaccines intended to prevent or mitigate COVID-19
  • Diagnostic and screening testing for COVID-19
  • Services related to diagnostic and screening testing:
    • An office visit to a hospital or health care provider to receive testing
    • Products related to testing
    • The administration of testing
    • Items and services furnished to an enrollee as part of testing

Diagnostic Testing for COVID-19

Diagnostic testing includes:

  • Testing intended to identify current or past infection.
  • Testing a person with symptoms consistent with COVID-19.
  • Testing a person because of contact tracing efforts.
  • Testing a person who indicates that they were exposed to someone with a confirmed or suspected case of COVID-19.
  • Testing a person after an individualized clinical assessment by a licensed health care provider.

Screening Testing for COVID-19

Screening testing is intended to identify people with COVID-19 who are asymptomatic and do not have known, suspected, or reported exposure to SARS-CoV-2.

Screening testing includes:

  • Workers in a workplace setting
  • Students, faculty, and staff in a school setting
  • A person before or after travel
  • At home for someone who does not have symptoms associated with COVID-19 and does not have a known exposure to someone with COVID-19.

What this Means for COVID Billing

The passage of SB 510 added Section 1342.2 to the CA Health and Safety Code. These regulations require health care service plans regulated by the state of California to pay for COVID-19 testing and vaccinations with no cost-sharing. Coverage without cost-sharing applies whether the member obtains testing or immunization services from an in-network provider or an out-of-network provider. Out-of-network providers without specifically negotiated rates must be reimbursed in the “amount that is reasonable, as determined in comparison to prevailing market rates.” These requirements for health care plans to pay for services from out-of-network providers are limited to the duration of the federal public health emergency.

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