On Jan. 6, the Department of Managed Health Care (DMHC) released All Plan Letters (APL) 21-003 and 21-004 in response to the public health order issued and amended earlier this week by the California Department of Public Health.
The public health order applies to hospitals in any region that has 0% ICU availability. In these counties, the public health order notes that hospitals shall transfer patients to other facilities. To facilitate transfers, APL 21-003 states that health plans may not prevent or delay the transfer of a plan enrollee pursuant to the order. The APL directs health plans to cover the medically necessary costs associated with the transfer and states that plans may not require prior authorization on a hospital’s transfer of plan enrollees under the order.
The APL also notes that health plans may continue to impose utilization management and prior authorization requirements for care if such requirements do not threaten the life or health of the enrollee.
With regard to out-of-network facilities, the APL states that the plans may not refuse to authorize medically necessary services provided by these hospitals, and the plans should reimburse the facilities and its providers for all medically necessary services at the “reasonable and customary” rate as described in California Code of Regulations, Title 28, section 1300.71 (a)(3)(B). Furthermore, the APL directs health plans to maintain all cost-sharing amounts for enrollees at the in-network amounts, regardless of where the care is delivered.
APL 21-004 is a reminder to plans of their continuing obligations to cover emergency services and care provided to enrollees and that such coverage includes reimbursement for appropriate transfers of unstable enrollees between hospitals in conformance with the requirements of the federal Emergency Medical Treatment and Labor Act.