COVID-19 Testing

We are providing CMS guidance on COVID 19 testing which addresses insurance questions as well as other issues, which are summarized below. Important note: this area is ever-changing as the pandemic heightens and testing requirements increase.

The Centers for Medicare & Medicaid Services (CMS)—in conjunction with the Treasury Department and Labor Department issued rules which implement mandates from the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

The FFCRA specifies that all COVID-19 testing approved by the Food and Drug Administration (FDA) or for which emergency use authorization (EUA) has been requested (until the EUA has been ruled on) and any associated medical services shall be covered by Medicare, Medicaid, and private insurance without any cost-sharing requirements for the patient. Coverage must be provided without “prior authorization or other medical management requirements.” In addition, the costs of testing and associated medical services for the uninsured can be paid through the National Disaster Management System (NDMS) at 110% of Medicare rates, and a state can opt to cover these costs for uninsured patients through their Medicaid program (with the costs effectively reimbursed in full by the federal government).

• Click here for “FAQS ABOUT FAMILIES FIRST CORONAVIRUS RESPONSE ACT AND CORONAVIRUS AID, RELIEF, AND ECONOMIC SECURITY ACT IMPLEMENTATION PART 43” and COVID 19 Section 6008, which offers guidance to clarify how insurance companies and group health plans implement FFCRA and CARES requirements and these are to be utilized when addressing your questions over my synopsis herein.
• Click here here for additional FAQs relating to Families First Coronavirus Response Act (FFCRA).

The guidance documents explain that the mandate to cover testing with no cost-sharing applies to all types of COVID-19 diagnostics – PCR tests, antigen detection tests, and serology tests – including when a patient is asymptomatic. However, the guidance also interprets the statute to apply only to testing done for “diagnostic purposes” and “when medically appropriate for the individual, as determined by the individual’s attending health care provider in accordance with accepted standards of current medical practice.” The agencies have defined an “attending health care provider” as any licensed provider making an “individualized clinical assessment.” Where the current law falls short is in the critical gap regarding what is or can be termed as non-medically appropriate, such as access to non-diagnostic testing. Under current guidance, health plans and other forms of coverage need only cover tests done for “diagnostic purposes” and “when medically appropriate for the individual, as determined by the individual’s attending health care provider in accordance with accepted standards of current medical practice.” This leaves a gap in access to and how to pay for other forms of testing such as employee and student return.

With that being said, there are four legal requirements within the laws:

1. Out-of-network testing entities cannot balance bill patients.
2. Health plans cannot decline to cover office, telehealth, urgent care, or emergency room visit that results in an order for a COVID-19 test and cannot charge any cost-sharing from the patient. This requirement applies to the “administration” of a COVID-19 test and all “items and services furnished to an individual” during visits “that result in an order for or administration of a [COVID-19 test].”
3. Health plans cannot exclude serology testing done for “individualized” diagnostic purposes when ordered or administered by a medical professional, nor can they exclude testing for asymptomatic patients with suspected exposure.
4. Self-insured employer health plans cannot escape these requirements. The statute and Trump administration guidance are crystal clear that all the COVID-19 testing coverage rules apply equally to self-insured employer health plans.

New York State Guidance:

In addition to the federal requirements for COVID-19 testing, the State of New York has introduced several mandates for testing through executive orders and agency guidance.  In addition to Governor Cuomo’s executive orders, state government agencies have also issued guidance for COVID-19 testing. The Department of Financial Services (DFS) issued two circular letters providing guidance for insurance issuers to comply with the Governor’s executive orders, Circular Letter’s No. 11 and No. 12 direct health insurance issuers to provide both in-network and out of network coverage for COVID-19 testing at pharmacies and for twice weekly testing of nursing and adult care facility personnel without cost sharing in order to comply with the Governors executive orders. So although Federal  law is clear that insurers must cover testing for of those persons who a medical providers deems as medically appropriate, New York has exercised its powers to apply a more expansive testing coverage requirement to New York’s private health insurance industry. Note, that although ERISA plans are exempted from these requirements, Circular Letter No. 11 indicates that third party administrators in the State are “strongly encouraged to apply the provisions” required for fully insured businesses.

Funding for uninsured patients

As part of the FFCRA and CARES Act, the Health Resources and Services Administration (HRSA) will reimburse healthcare providers, generally at Medicare rates, for testing uninsured patients for COVID-19. Balance billing is not allowed and there will be no cost for those who have no insurance.

Somos and/or the Medical Providers who are to provide the professional services under the Agreement will not send any invoice or bill any student or staff member tested.