ACHP: 5 Policy Recommendations about COVID-19 Testing Coverage

The Alliance of Community Health Plans (ACHP) has issued five recommendations to CMS regarding COVID-19 testing coverage.

“As Americans return to their workplace, children return to in-person school and social events begin to return to pre-pandemic normalcy, it is essential that the Administration reaffirm the financial responsibility for COVID testing,” the payer organization’s letter began. “To protect the premium dollar of every consumer, it is essential that the Administration reassert that health plans are only responsible for health-related testing.”

ACHP health plans have reported that testing prices are rising, with one payer seeing a 16 percent increase in coronavirus testing prices from August 2020 to around August 2021 across all lines of business.

Additionally, although the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) were clear that payers are only responsible for health-related coronavirus testing, ACHP health plans have continued receiving testing claims that they suspect are work-related.

The health plans called for policymakers and stakeholders to collaborate in order to assign a purpose indicator to coronavirus testing claims. Leveraging ICD-10 codes would be a simple way to help separate the health-related coronavirus testing claims from the work-related ones. But ACHP emphasized that establishing a national strategy was appropriate.

The second recommendation addressed preventing employers from rewarding unvaccinated workers with free coronavirus testing. Policymakers should issue guidance for employers clarifying that employers are obligated to cover work-related coronavirus testing.

“In addition, we recommend the Administration consider allowing employers to share in the financial responsibility for testing with employees who choose to remain unvaccinated and opt for weekly testing,” the letter stated. “We note that there should be appropriate exceptions for individuals who are not vaccinated under a recognized exemption.”

Third, ACHP recommended that policymakers lower the coronavirus testing Medicare reimbursement rate back to prepandemic levels. The Administration elevated the rate during the first wave of COVID-19 in order to incentivize testing, but ACHP argued that the higher prices no longer served that purpose. 

Fourth, the payer organization suggested that CMS permit managed care organizations to use utilization management strategies in order to reduce coronavirus testing at more costly sites. Without that permission, health plans pay more for each test, driving up future premiums.

Finally, the payer organization urged CMS to allow some of the Public Health and Social Services Emergency Fund to go toward reestablishing state testing sites, which proved very useful in 2020. The funds were originally designated to contact tracing and expand the nation’s ability to deliver coronavirus tests.

The contentions around who should reimburse for coronavirus testing is part of a larger conversation about the price of coronavirus testing.

Payers have asserted that out-of-network providers are engaging in price gouging. According to an AHIP report on the subject, 54 percent of coronavirus tests in the commercial payer market cost $185 or more. This was in spite of the fact that coronavirus testing at expensive sites of care has declined.

Some payers have started new partnerships in order to reduce lab testing costs.  For example,  Blue Cross and Blue Shield of North Carolina (Blue Cross NC) reduced its lab service costs by $112 million by working with a laboratory insights company. Over the last four years, Blue Cross NC saw nearly all of its lab testing services become in-network.

Aetna named coronavirus testing when the payer shared its Medicare Advantage benefits for Medicare open enrollment 2022. Coronavirus testing will have no copay attached for seniors on the payer’s Medicare Advantage plan, along with diabetes eye exams and other services.

As coronavirus testing becomes more common, payers, employers, policymakers, and other stakeholders will have to work together to determine a more permanent strategy for reimbursement.