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How Are Payers Covering COVID-19 Testing for High-Risk Patients?
Populations most vulnerable to high out-of-pocket costs for COVID-19 testing include low-income, uninsured, underinsured, and immigrants.
Updated 03/13/2020: This article has been updated to include information from a CMS FAQ regarding essential health benefit coverage.
Updated 3/27/2020: Since this article was originally published on March 9, 2020, the landscape of testing coverage has changed. The passage of the Families First Coronavirus Response Act required that private payers and Medicaid cover coronavirus testing without cost-sharing. The bill still left some gaps in coverage, however. Please refer to our article on the subject for more information.
As the nation fights the spreading novel strain of coronavirus, payers must continue to be clear about which patients will receive coverage for their COVID-19 testing and which payers are providing COVID-19 testing coverage.
For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.
In the four months since it was first detected in Wuhan, China, the novel strain of the coronavirus called COVID-19 has already touched six of the seven continents. In the US, incidents of coronavirus have largely struck the west coast, according to data gathered by Johns Hopkins University researchers, resulting in over 20 deaths.
Payers across the nation have risen to the challenges of COVID-19.
“As our country prepares for the possibility of widespread infections and takes action to mitigate the impact, our priority is the health and well-being of the people we serve,” the board of America’s Health Insurance Plans said in a recent statement. “There are three critical areas health insurance providers are proactively addressing right now: Prevention, testing, and treatment.”
The payer organization committed to lower out-of-pocket costs for those infected with COVID-19, work with providers to make treatments available to infected patients, and to educate the public about ways to prevent the spread of COVID-19.
While these efforts have been well-intentioned, there has been some confusion regarding what populations of patients have the COVID-19 test covered by insurance and which payers are covering them.
For instance, in a recent briefing, Vice President Mike Pence stated, “HHS has already denominated a test for coronavirus to be an essential health benefit, which ensures that it will be covered by people’s private health insurance. It’ll be covered by Medicare and Medicaid.”
However, the comment has received significant objections from industry leaders and news outlets who point to certain contradictions to the vice president’s implication that all members of private health plans will receive coverage for the COVID-19 test.
With affordability being a major barrier to access to care nationwide, it is critical to clarify which populations are covered and what that payer coverage entails.
Which high-risk populations see COVID-19 test coverage?
Medicare patients with COVID-19 can receive coverage for the testing under Medicare Part B. Medicare Advantage patients will rely on their payers’ discretion for coverage and, similarly, Medicaid and CHIP beneficiaries may or may not have coverage for their testing depending on their state Medicaid programs’ discretions.
For those on short-term limited duration health plans, large group health insurance marketplace plans, and self-insured plans, payers may not be required to incorporate essential health benefits.
The uninsured, underinsured, and immigrants are particularly at risk for not having sufficient coverage to seek out care or being uninformed about their options.
Which payers are covering the COVID-19 testing?
Medicare patients can receive coverage for tests under Medicare Part B. However, if the Part B deductible applies to the patient—the deductible is $198 for this year—then the patient must cover up to that amount before Medicare’s coverage kicks in. Once the patient pays up to the deductible amount, they continue to pay 20 percent on the Medicare price with no out-of-pocket healthcare spending limit.
Medicare Advantage plans that decide to cover COVID-19 testing will fulfill the safe harbor to the Federal anti-kickback statute.
“CMS will exercise its enforcement discretion regarding the administration of MA organizations benefit packages as approved by CMS in conjunction with implementing a voluntary waiver or reduction of cost-sharing for COVID-19 laboratory tests as described,” CMS has stated.
States’ Medicaid programs and individual and small group market insurance plans have taken different positions on coverage for testing.
“Testing and diagnostic services include any medical procedures or supplies recommended by a physician or other licensed practitioner to enable him/her to identify the existence, nature or extent of illness and whether a person is sick,” a CMS fact sheet explained. “Though these are commonly covered services, testing and diagnostic services are an optional benefit category, and can vary by state. However, children are eligible to receive all medically necessary testing and diagnostic services.”
At present, California, New York, Oregon, and Washington have required all state health payers to waive the costs of COVID-19 testing kits.
In general, individual and small group health insurance marketplace plans must offer coverage for COVID-19 testing under their essential health benefits.
“Whether any particular diagnostic or laboratory service is covered by a plan varies, and is based on the specific benchmark plan selected by each state and the terms of the plan,” a CMS fact sheet warned. “Large group market plans and self-insured plans are not subject to EHB coverage requirements.”
On March 13, CMS released an Essential Health Benefit (EHB) Coverage FAQ that outlined the required COVID-19 coverage for plans with essential health benefits.
Non-grandfathered health insurance plans are required to cover ten EHB categories, the FAQ explained. The entities responsible for establishing the EHB-benchmarks for the ten EHB categories are the states and the District of Columbia, all of which now require coverage for COVID-19 diagnosis and treatment. Most also cover hospital quarantines as a medically necessary hospitalization and even home quarantines can be covered but may require prior authorization.
Aetna, Cigna, and UnitedHealthcare are among the largest payers that are waiving copays and cost-sharing for testing kits. Self-insured plans may opt out, however.
In addition to covering basic testing kits, payers are actively addressing other major hurdles.
As patients overwhelm hospitals and providers for coronavirus testing kits, payers are turning to telehealth solutions to help assess whether a patient truly needs a testing kit.
“Aetna members should use telemedicine as their first line of defense in order to limit potential exposure in physician offices,” Aetna’s website advises.
Aetna is temporarily eliminating its co-pay on telemedicine visits so that all commercial health plan patients can be diagnosed without going out in public. The payer is also covering all Aetna Commercial members’ use of the Medicare Advantage virtual evaluation and remote monitoring visit benefit, again to avoid the risks of putting infected individuals in a public setting where the disease could spread more rapidly.
Apart from waiving all co-pays, coinsurance, and deductibles on COVID-19 testing, Cigna has established two call lines—one for those who are struggling with administrative barriers related to COVID-19 claims and another for mental and behavioral healthcare support related to the pandemic.
The second line connects patients who are experiencing anxiety, stress, and other mental healthcare concerns with healthcare professionals who can coach them through coping mechanisms.
Many payers have also set up web pages that share basic information about the novel coronavirus and directing members to the CDC website for more information.
What about coverage for uninsured individuals?
As COVID-19 seems to gain strength, many payers are on the frontlines helping patients get access to care. However, the uninsured population remains at high risk.
On March 2, 815 healthcare experts and organizations in academia and law wrote to Vice President Pence and federal, state and local leaders across the nation to advise on a correct response to COVID-19.
Among its other demands, the letter called on government officials to act on specific COVID-19-related healthcare demands, particularly regarding the lower income, uninsured, and immigrant populations. Those demands included that the government must
- Work with payers to ensure access to care and testing for the uninsured
- Make healthcare facilities into immigration enforcement-free zones
- Maintain chronic disease healthcare programs, specifically for kidney disease, cancer, and opioid therapy
“Control efforts will be less effective if some fail to seek appropriate diagnosis or care due to large out-of-pocket costs or copays,” the experts wrote. “Out-of-network or other insurance provisions cannot be allowed to disrupt local triage and patient allocation plans.”
Other vulnerable populations include nursing home residents, incarcerated individuals and their corrections officers or other personnel, and homeless people on the streets or in shelters.
A true test of public and private payers’ capabilities will be how they serve these populations.
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