ACHP Asks CMS To Set At-Home COVID-19 Testing Coverage Standards

In a letter to CMS, the Alliance of Community Health Plans (ACHP) has requested that the federal government establish certain requirements for at-home COVID-19 testing coverage.

“We support the Administration’s goal to improve access to FDA-approved COVID at-home tests while protecting the premium dollar of every patient, employer and taxpayer,” the organization began. “However, the responsibility for public health surveillance testing, including at-home tests, remains with the federal government.”

ACHP offered five recommendations to the Biden administration regarding how to address coronavirus testing.

First, the payer organization urged the administration to standardize at-home coronavirus testing, specifically regarding how often individuals should get tested in order to control the spread of the disease. In order to eliminate hoarding and excessive utilization, the federal government should research the optimal frequency and release a standard, ACHP stated.

Second, claims should include the cause for the at-home coronavirus test. Having this information in the claim would improve claims coding processes.

Third, ACHP highlighted the ample opportunity for fraud under the current standard. Payers should have the ability to deny coverage for at-home testing claims that may be fraudulent, the letter argued. 

Otherwise, if all at-home coronavirus tests are viable for reimbursement, different consumers could submit the same test to their payers or they could resell or return tests for which they received insurance coverage.

Fourth, the federal government needs to take on price gouging of coronavirus testing, including at-home tests. 

Payers first began to voice concerns about price gouging for coronavirus tests in 2020 and these concerns remain true a year later. AHIP reported that out-of-network providers for coronavirus testing lab work may triple the price of the test, compared to its actual cost.

Lastly, the payer organization requested that the federal government set a timeframe for claims for at-home coronavirus tests to be submitted. Without a deadline, ACHP said that claims processing and payments would be delayed. The organization pointed out that other manual claim submissions have established timeframes for submission.

Overall, the operational challenges that at-home coronavirus testing poses were a key consideration that ACHP brought up to CMS. Consumers will have to submit reimbursement claims manually, which puts considerable strain on health insurers. 

The healthcare industry is currently trying to move away from manual claim submission and boost electronic payment systems. According to the CAQH 2020 Index, 71 percent of the payer industry had adopted fully electronic transactions in 2020. Although most health plans use electronic payment, the move toward this model has creeped upward very slowly in the past four years.

In the CAQH 2020 Index, industry experts argued that transitioning to electronic fund transfer methods could save the healthcare industry $426 million. Moreover, electronic methods of transferral can be significantly faster than manual submission, potentially reducing administrative burden.

“To mitigate the extraordinary operational barriers and improve consumers’ ability to access at-home tests, ACHP encourages the Administration to consider alternative approaches that would build on the successful consumer, health plan and government partnership model utilized for COVID-19 vaccinations,” the ACHP letter shared.

The upfront cost of the test may still pose a social determinant of health barrier to low-income individuals, ACHP also noted. 

The letter suggested that the government could implement an existing approach to reimburse for at-home COVID-19 tests, channeling funds from the Paycheck Protection Program and Health Care Enhancement Act or adopt the Say Yes! COVID Tests initiative approach in order to reduce barriers.

ACHP also provided feedback on the government's coverage for coronavirus testing earlier in 2021.