The Public Health Emergency (PHE) officially ended on May 11th, and with that, there are changes to your group health insurance regarding special enrollment, deadlines for COBRA continuation coverage, and claim submission.

The Medi-Cal redetermination procedure started in April 2023. This is the procedure by which Medi-Cal (California’s State Welfare Fund) assesses if a person still meets the requirements for Medi-Cal. During the early 2020 pandemic, this process was put on hold. Therefore, if you have employees who are currently enrolled in Medi-Cal, they will need to be recertified and may no longer be eligible for Medi-Cal. These workers will have a 60-day Special Enrollment Period (SEP) to sign up for your company’s health plan. The Medi-Cal eligibility determination process will be carried out monthly for the 15.4 million Californians who receive it. People who first signed up for Medi-Cal in April but are now discovered to be ineligible for Medi-Cal will begin looking for health insurance in June and will have a 60-day window to apply. Medi-Cal will carry out this redetermination process on a monthly basis. The original May Medi-Cal enrollees, who are now found to be ineligible, will search for health insurance in July.

A 60-day special enrollment period (SEP) will be given to people who are no longer eligible for Medi-Cal to sign up for an employer-sponsored plan that they had previously rejected. Due to this redetermination, groups can experience fresh enrollments.

Following is a recap of the coverage for Covid-19 treatment plans based on Carriers:

1 Blue-Shield:

For six months after the conclusion of the Public Health Emergency (PHE), through November 2023, members participating in fully insured plans will not see any changes to their coverage or cost-sharing. As part of this, members will continue to get a cost-share waiver for diagnostic testing, which covers the cost of eight at-home test kits per member per month, as well as medicines and vaccinations. After this six-month extension, in-network coverage for these services will continue at no member cost-share; however, member cost-share might be assessed based on a member’s out-of-network plan benefits. The present in- or out-of-network benefits system, which determines coverage for services other than pharmaceuticals, will continue to apply now that the PHE is over.

After the PHE expires, self-funded group plan sponsors are no longer required to cover members’ diagnostic testing copayments. According to a member’s plan benefits, coverage and member cost-shares will be applied for both in- and out-of-network COVID-19 testing and testing services. When services are delivered within a network, the Advisory Committee on Immunization Practices (ACIP) preventive services recommendations will still call for coverage and cost-share waivers for the COVID-19 vaccines, but neither out-of-network coverage nor out-of-network cost-sharing will be required. Regarding coverage and cost-sharing for treatment, which will still be determined by a person’s in- or out-of-network benefits, nothing will change.

When deciding on any plan modifications for the upcoming plan year, we strongly advise you to take these benefit adjustments into account.

2. Oscar

At-home tests
Oscar now covers up to two $0 at-home COVID-19 tests per month (per member) when purchased at an in-network location. If you need more at-home tests, you’ll just need to pay the out-of-pocket cost. (And don’t worry, at-home tests are still a low-cost way to get tested!) You can log into your member account to search your network.

Lab tests
Lab testing for COVID-19 is still covered under your clients’ health plan benefits. This includes COVID-19 PCR or rapid antigen tests. Your clients’ standard lab deductible and cost-share may apply but know that they’re covered for in-network labs.

  • You can get a reliable over-the-counter COVID rapid test at a variety of retailers (like CVS). These do not require a deep nasal swab like the PCR testing early in the pandemic did and are generally easy to use. 
  • If you go to the pharmacy counter, you may be able to present your member ID and ask them to bill your insurance just like you would a medication, at no cost to you.

3. Anthem

These benefits are extended for Fully Insured clients:

  • Diagnostic and screening testing for COVID-19
  • COVID-19 immunization
  • Items and services intended to prevent or mitigate COVID-19
  • Therapeutics
  • Up to 8 over-the-counter tests per month

They will continue to be covered without:

  • Cost Sharing and prior authorization.
  • Utilization Management.
  • In-network requirements.

Out-of-network provider reimbursement must remain at least 125% of Medicare reimbursement through November 11, 2023, and at least 100% of Medicare reimbursement after that. 

Administrative Service Only local clients in California can choose to customize their COVID-19 benefits as part of normal plan administration.

4. Health Net

Health Net of California, Inc. (Health Net) will continue covering COVID-19 tests, vaccines, and therapeutics from any licensed provider (in or out of network) with no prior authorization or member cost sharing through November 11, 2023. After this period, members may continue to access COVID-19 tests, vaccines, and therapeutics with no prior authorization or cost-sharing when they access these services through their health plan’s network.

If a member’s plan offers out-of-network (OON) benefits, they may still receive therapeutics OON but may be subject to cost sharing.

  • Over-the-counter (OTC) COVID-19 tests: Health Net members can have up to eight free OTC at-home COVID-19 tests per month.
  • Member notification: Health Net will communicate the end of PHE and the impact of the benefit changes to members 60 days prior to November 11, 2023.

Please contact us at Solid Health Insurance Services if you wish to receive a free health insurance quote for your small business. Our mission is to find affordable health insurance for you and your employees which meets your budget and medical needs.

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