By Kelly Hughes and Haley Nicholson
Throughout the COVID-19 pandemic, having access to affordable testing and treatment has remained a top concern for many Americans. Mixed interpretations of evolving federal guidance have contributed to confusion around coverage for testing and treatment among hospitals, payers and the public. Federal and state policymakers, as well as private insurance plans, are addressing gaps and mitigating some affordability challenges that could arise from, or prevent timely access to, COVID-19 testing and treatment.
This blog post unpacks the latest federal guidance and state action related to these issues.
Together, the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security (CARES) Act require health insurers, including self-insured employer plans, to waive cost sharing for COVID-19 tests, as well as tests to rule out related conditions, such as influenza. Plans and insurers, including Medicare, Medicaid and most private insurance plans, must also cover COVID-19 tests and associated care when ordered. In late June, the departments of Labor, Health and Human Services and the Treasury released additional guidance to clarify how health plans and issuers should implement coverage provisions for their plans.
The FFCRA had several requirements for COVID-19 testing coverage for the insured and uninsured. Individuals enrolled in group-sponsored, self-insured or individual plans should receive COVID-19 testing with no cost sharing—including copays, deductibles or coinsurance—for diagnostic tests and relevant care, if deemed medically appropriate. This determination can be made by a medical provider within the scope of licensure but does not have to be a person’s primary care or other established provider.
For uninsured individuals, the FFCRA and the Paycheck Protection Program and Health Care Enhancement Act (PPPHCEA) appropriated $1 billion to reimburse providers performing COVID-19 testing. The CARES Act provided $100 billion in provider relief funds and an additional $75 billion came from the PPHCEA, with a portion of total funding from both bills to support testing and treatment for the uninsured. In order for providers to receive reimbursement for these services, the CARES Act also established that plans must reimburse providers at a negotiated rate or cash price.
With so many moving parts in the federal laws and related guidance, it is evident that insurers, employers and providers, among others, may be confused on the coverage requirements for COVID-19 testing and treatment.
Many states are taking steps to ensure that gaps in coverage do not create barriers to individuals receiving necessary testing and treatment.
Medicaid enrollees typically have little to no cost sharing as states are required to cover testing and treatment costs, without cost sharing, to be eligible for a 6.2% increase in the regular Medicaid match rate passed under the FFCRA. To date, all 50 states are receiving the enhanced match rate for the duration of the public health emergency.
On the testing front, at least 18 states and Washington, D.C., are requiring or recommending that private health insurers provide coverage for testing that exceeds the federal standard. For example, Colorado requires insurers to cover approved tests without cost sharing, even if the visit does not result in an order for or administration of a COVID-19 test.
Several states, including North Dakota, Idaho and Texas, are encouraging short-term limited duration plans (STLDs) to waive cost sharing for testing. Washington explicitly requires STLDs to waive cost sharing for COVID-19 testing.
States are also taking targeted action to ensure testing coverage for special populations, such as residents and staff of nursing homes. For example, a directive by New York’s department of financial services requires insurers to cover and waive cost sharing for twice-weekly testing of nursing home and adult care facility personnel. In West Virginia, an executive order requires insurers to cover and waive cost sharing for testing of all residents and staff of nursing homes, assisted living facilities, residential care communities and licensed child care centers.
At least seven states and Washington, D.C., require or recommend that private health insurers waive cost sharing for COVID-19 treatment. The Michigan Department of Insurance and Financial Services brokered a deal with nearly all insurance companies in the state to cover COVID-19 treatment, including primary care visits, laboratory testing, emergency room visits, ambulance services and medication, without cost sharing.
Some private health insurers have voluntarily waived some or all cost sharing for diagnostic testing and treatment services. A detailed list from America’s Health Insurance Plans can be found here.
Uninsured patients may still receive a bill for COVID-19 testing because federal law does not require a provider to seek reimbursement from the federal government for testing an uninsured patient. Therefore, states are considering ways to cover testing costs for uninsured people through Medicaid demonstration waivers and legislation. For example, Minnesota HB 4556 extends medical assistance coverage for COVID-19 testing for uninsured individuals, as permitted by the FFCRA.
State policymakers and health officials will continue to address critical gaps in access to and support for COVID-19 testing as the federal government continues to clarify and enforce existing laws and guidance.
Kelly Hughes is a program director for NCSL’s Health Program.
Haley Nicholson is a senior policy director for Health and Health Human Services with NCSL’s State-Federal Team.