Piggy Bank Mask Money

Ensuring physicians can administer tests and vaccines is critical to putting the COVID-19 pandemic behind us. This is why the California Medical Association (CMA) sponsored legislation that requires health plans and insurers to cover COVID-19 testing and vaccinations during the pandemic without barriers like patient cost-sharing or prior authorizations.

This bill—SB 510, authored by Senator Richard Pan, M.D.—was signed into law and will ensure that all Californians, regardless of race, income or geographic region are able to receive vaccination and testing, which will remain necessary until the conclusion of the pandemic. This bill also implements valuable lessons learned over the course of the pandemic, setting up a framework in preparation for future public health crises so the state can be prepared for the next outbreak.

The new law takes effect January 1, 2022, but is retroactive to the beginning of the public health emergency, which was declared on March 4, 2020.

SB 510 requires payors to cover COVID-19 testing and vaccine administration, regardless of the provider’s network status. If the provider would have otherwise been entitled to receive cost-sharing for the service, the payor must reimburse the physician for the lost cost-sharing amounts.

SB 510 also prohibits payors from shifting the financial risk of COVID-19 testing and vaccine administration to contracted providers, unless both parties have negotiated and agreed to a new contractual provision. This is critical because some health plans and insurers have been shifting the financial risk of critical COVID-19 diagnostic testing to physicians on the front lines caring for their patients by reimbursing far below the cost of the test itself.

As such, the bill requires payors to negotiate a payment rate for in-network providers, rather than unilaterally imposing a contracted rate. For non-contracted providers, payors must reimburse for COVID-19 testing and vaccine administration at a rate that is reasonable when compared to prevailing market rates in the geographic region where the service is rendered. Providers are required to accept this as payment in full and balance billing of patients is not allowed.

CMA earlier this year asked the California Department of Managed Care and the California Department of Insurance to investigate concerns that certain payors were impeding patients’ access to appropriate and necessary COVID-19 testing in violation of state and federal law, and profiting at the expense of treating physicians.

SB 510 is critically important legislation to ensure that barriers to testing and vaccination remain minimal, physicians are protected from bad behavior by health plans, and patients have no out-of-pocket costs for these necessary services.

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