January 10, 2025
Area(s) of Interest:
Disaster Relief
What You Need to Know: California regulators tell insurance companies they must act quickly to ensure patients affected by the SoCal wildfires have access to medically necessary care without unnecessary barriers.
California’s two health insurance regulators have issued guidance to payors, reminding of their obligations under state law to ensure continued access to medically necessary health care services during the State of Emergency due to the Southern California wildfires.
Both the California Department of Insurance and the California Department of Managed Health Care sent notices yesterday directing health insurance companies to remove unnecessary barriers to care, and to submit emergency plans to their regulators detailing the actions they have taken or are in the process of taking to ensure that the health care needs of its enrollees are met, including:
- Relaxing time limits for or suspending requirements for prior authorization, precertification or referrals.
- Extending claims filing deadlines.
- Suspending prescription refill limitations; allowing impacted insureds to refill prescriptions at out-of-network pharmacies and covering the prescriptions as if they were obtained from a network pharmacy; allowing earlier refills; providing expedited shipping options for mail-order prescriptions at no additional cost to the insured; and waiving any increased cost sharing obligations for using retail pharmacies instead of mail-order pharmacies.
- Authorizing an enrollee to replace medical equipment or supplies.
- Allowing an enrollee to access an appropriate out-of-network provider if an in-network provider is unavailable due to the state of emergency or if the insured is out of the area due to displacement.
- Having a toll-free telephone number that affected enrollees can call for assistance.
Under state law, health plans and insurers operating in counties affected by an official state of emergency are required to act quickly to ensure patients in areas affected by wildfires and other disasters have continued access to care, and must file their emergency plans with the appropriate regulator within 48 hours of the emergency declaration.
Medicare/Medicaid
Medi-Cal Rx
Medi-Cal Rx is also permitting emergency overrides on pharmacy claims for members residing in Los Angeles and Ventura Counties. These overrides will be accepted for claims with dates of service of January 7 through February 7, 2025. However, the California Department of Health Care Services (DHCS) has indicated it will extend this flexibility if needed. The DHCS guidance for pharmacy providers does not indicate how/if Medi-Cal Rx will allow impacted insureds to refill prescriptions at out-of-network pharmacies. The California Medical Association (CMA) has inquired about this issue and will report back when we have more information.
Centers for Medicare and Medicaid Services
CMA is also urging the Centers for Medicare and Medicaid Services to take action to assist physicians and patients affected by the devastating wildfires, including:
- Extending claims filing deadlines.
- Eliminating prior authorization and other reporting requirements
- Invoking extreme and uncontrollable circumstances exemptions for the MIPS quality reporting program to exempt physicians from reporting and penalties
- Providing accelerated or advance Medicare payments
CMA Assistance for Physicians
CMA is working with regulators and payors to understand the flexibilities offered by each payor and will soon publish a guide to help ensure patients continue to have appropriate access to medically necessary health care services.
Physicians who are having trouble getting care for patients affected by the wildfires can contact the CMA Center for Economic Services for assistance at (800) 786 4262 or economicservices@cmadocs.org.
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