By Jack Pitsor and Haley Nicholson
As the number of confirmed coronavirus disease cases continues to rise across the United States, bolstering access to COVID-19 testing and treatment is a growing concern.
Lawmakers, public health officials and other stakeholders are working to increase the number of available testing kits and ensure the country’s health system has the capacity to provide testing. There is, however, another major barrier impeding access to COVID-19 testing and treatment: costs to patients.
In the midst of a global pandemic, there is general confusion over what patients are required to pay, if anything, for COVID-19 testing and treatment. Federal and state policymakers are taking several steps to lower patients’ costs for COVID-19 testing and treatment. But what is the scope of services that are or could be covered through these federal and state mandates? What health insurance plans do these mandates apply to?
This post highlights state and federal actions related to insurance coverage and patient cost-sharing for COVID-19, as well as information regarding the type of health insurance plans affected and services covered.
Due to concerns that costs may discourage patients from seeking necessary COVID-19 testing and other related treatment, many state policymakers are looking to reduce or waive cost-sharing requirements. Through directives by governors and state departments of insurance, at least 12 states—including Alaska, Arizona, California, Colorado, Kentucky, Maryland, Massachusetts, New Hampshire, New Mexico, New York, Nevada and Washington—are requiring insurers to cover medically necessary COVID-19 testing and/or treatment without cost-sharing to patients.
The scope of state responses to COVID-19 cost-sharing varies, but overall, the majority of state lawmakers and officials are aiming to ensure patients have limited or no out-of-pocket expenses for diagnostic testing.
Beyond executive directives, states such as Michigan, Minnesota and South Carolina are considering legislation related to waiving out-of-pocket costs for COVID-19 testing and related services. A handful of states—such as Oregon and Pennsylvania—have reached agreements with insurers to waive cost-sharing for patients in need of COVID-19 testing and treatment. Other states—such as Florida, Georgia, Missouri, Tennessee and West Virginia—have requested, but not required, insurers to lower or remove costs for patients seeking COVID-19 testing and treatment. States such as Michigan and Texas are removing any patient cost-sharing requirements for COVID-19 testing, treatment and/or recovery for those who receive health benefits through Medicaid or the Children’s Health Insurance Program (CHIP).
Additionally, many states are mandating or encouraging insurers to waive any co-payment, deductible or coinsurance for a hospital, emergency room or urgent care visit related to COVID-19 testing and treatment. States are also directing or encouraging insurers to lower cost requirements for telehealth services in order to increase access for patients and limit exposure to the virus. Lastly, many states are working to ensure patients can receive early refills for prescriptions due to COVID-19 concerns without any associated costs.
State directives and legislative mandates apply to certain state-regulated insurance coverage options, such as private health insurance plans sold on the individual and small group marketplaces, Medicaid, short-term limited duration plans and state employee health plans. However, these state actions—like most state insurance regulations—do not affect those covered by “self-funded insurance plans,” usually offered by larger employers. Due to the federal Employee Retirement Income Security Act of 1974 (ERISA), states cannot guarantee COVID-19 testing free of cost-sharing for those enrolled in self-funded insurance plans.
After testimony by Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Disease, federal lawmakers prioritized making COVID-19 testing available to more people in the U.S., regardless of their insurance status. Federal policymakers and the administration are looking to address this in a few ways.
The Centers for Medicare and Medicaid Services (CMS) released guidance on how states can modify their Medicaid plans to eliminate cost-sharing for services like COVID-19. In addition, the president’s emergency declaration gives states more flexibility for their Medicaid programs such as waiving prior-authorization requirements.
Also, CMS published Medicare reimbursement amounts for providers giving COVID-19 testing. The administration released information on existing federal rules for health coverage provided through individual and small group insurance markets as they apply to testing and treatment of COVID-19.
In an effort to get emergency surplus funding out to states in a timely way, the president signed into law HR 6201, the Families First Coronavirus First Response Act. The bill contains supplemental funding for state, territorial and local partners across several funding priorities, including cost to patients for COVID-19 testing and medical treatment.
For example, the legislation increases Medicaid funding to the states and requires states to waive cost-sharing requirements for COVID-19 testing, but not treatment. Additionally, the legislation requires private insurers—as well as all federal health programs and health insurance plans for federal civilian employees—to cover COVID-19 diagnostic testing without cost-sharing to patients or prior authorization requirements.
The bill also provides $1 billion to the National Disaster Medical System to reimburse provider costs for testing uninsured individuals.
Jack Pitsor is a research analyst in NCSL’s Health Program. Haley Nicholson is senior policy director in NCSL's State-Federal Relations Division.