The end of the Public Health Emergency (PHE) on May 11 has brought changes in health insurance coverage for services related to COVID-19. However, some coverage has not changed. Read the article below to understand what’s changed on the federal level and the exceptions that are in place for California.
After the end of the PHE, major changes include the following:
• Plans must continue to cover COVID-19 vaccines from an in-network provider at no cost. However, plans may impose cost sharing if someone gets a vaccine from an out-of-network provider.
• Plans will no longer be required to pay for lab and over-the-counter diagnostic testing.
• Stand-alone telehealth benefits: Large employers were able to offer stand-alone telehealth benefits and other remote care services to those ineligible for coverage under other group health plans during the PHE. These arrangements will not be permitted after the PHE ends.
California Exceptions
Most coverage requirements regulated by California remain intact. Here's an overview of the key points:
• State law requirements for coverage apply to health insurance policies regulated by the California Department of Insurance and health plans regulated by the Department of Managed Health Care.
• Health insurers in California are currently required to cover COVID-19 diagnostic testing, vaccines, and therapeutics without cost-sharing for patients, regardless of in-network or out-of-network providers.
• The requirement for coverage without cost-sharing from out-of-network providers will expire six months after the federal public health emergency ends, on November 11, 2023.
• Starting November 12, 2023, individuals with coverage for out-of-network benefits may have to pay cost-sharing for COVID-19 diagnostic testing services, vaccines, therapeutics, and related health care services.
Here are links to additional sources to navigate these changes:
1. California Health and Human Services guidance
2. California Department of Insurance guidance
3. Federal guidance
Source: Catro, A. (2023, May 9). Ending the COVID-19 PHE Fact Sheet. California Department of Insurance. https://www.insurance.ca.gov/01-consumers/140-catastrophes/upload/Ending-the-COVID-19-PHE-Fact-Sheet.pdf
The below table details coverage changes from our carrier partners and will be frequently updated. Please note that California extended the PHE for all plans regulated by the Department of Managed Health Care for six months.
| Carrier | COVID-19 vaccines, including boosters | COVID-19 at-home test kits (OTC test kits) | Lab tests (rapid diagnostic and swab-and-send tests) |
| Aetna | Members pay $0 for the vaccine at in-network locations. | Members will pay the retail cost of test kits. | Members will pay the copay, coinsurance or deductible. |
| Anthem | COVID-19 immunization covered without cost-sharing, prior authorization, utilization management, or in-network requirements. | Up to 8 over-the-counter tests per month covered without cost-sharing, prior authorization, utilization management, or in-network requirements. | Diagnostic and screening testing for COVID-19 covered without cost-sharing, prior authorization, utilization management, or in-network requirements. |
| Blue Shield of California | In-network: $0 cost-share. Out-of-network: cost-share based on plan benefits. |
In-network: $0 cost-share. For up to eight tests per month. Out-of-network: cost-share based on plan benefits. |
In-network: $0 cost-share. Out-of-network: cost-share based on plan benefits. |
| Cigna | Covered under the preventive benefit at 100% for in-network only for most plans. Out-of-network coverage based on plan benefits. |
Not covered under the pharmacy or medical plan benefits. | Covered at cost-share under the lab benefit based on place of service. Out-of-network coverage based on plan design. |
| HealthNet | $0 cost-share | $0 cost-share | $0 cost-share |
| Kaiser Permanente – Commercial Members in CA (Next six months) | $0 cost-share | $0 cost-share | $0 cost-share |
| Kaiser Permanente – Other States and Plans (Varies) | Varies by state and plan benefits. | Varies by state and plan benefits. | Varies by state and plan benefits. |
| Sutter | $0 cost-share | $0 cost-share | $0 cost-share |
| UnitedHealthcare | $0 cost-share for in-network services. | No coverage, unless mandated by state regulations. | Coverage in line with member's standard medical plan |
| Western Health Advantage | $0 cost-share | $0 cost-share | $0 cost-share |