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Health plans banned from denying coverage of COVID-19 tests for asymptomatic individuals

Providers may seek federal reimbursement for costs incurred for COVID-19 testing or vaccines to those who are uninsured.

Susan Morse, Managing Editor

New guidance issued by the Biden Administration today makes it clear that private group health plans cannot use medical-screening criteria to deny coverage for COVID-19 diagnostic tests for members who are asymptomatic or who have no known or suspected exposure to COVID-19. 

Such testing must be covered without cost sharing, prior authorization or other medical management requirements imposed by the plan or issuer, according to the Centers for Medicare and Medicaid Services, the Department of Labor and the Department of the Treasury.

This guidance also highlights avenues for providers to seek federal reimbursement for costs incurred when administering COVID-19 diagnostic testing or a COVID-19 vaccine to those who are uninsured. 

One such existing program is through the Provider Relief Fund program, which has a separate effort for providers to submit claims and seek reimbursement on a rolling basis for COVID-19 testing, COVID-19 treatment and administering COVID-19 vaccines to uninsured individuals.

The HRSA Uninsured Program has already reimbursed providers more than $3 billion for the testing and treatment of uninsured individuals, and expects to see vaccine administration claims as states scale up their vaccination efforts. 

HHS is seeking comment on strategies to connect those without insurance to care from providers participating in this fund.

WHY THIS MATTERS

The Departments have received many questions about plan and issuer responsibility to cover COVID-19 diagnostic testing for individuals who are asymptomatic and have no known or suspected recent exposure to COVID-19. 

This announcement clarifies the circumstances in which group health plans and issuers offering group or individual health insurance coverage must cover COVID-19 diagnostic tests without cost sharing, prior authorization or other medical management requirements when a licensed or authorized healthcare provider administers or has referred a patient for such a test. 

For example, covered individuals wanting to ensure they are COVID-19 negative prior to visiting a family member would be able to be tested without paying cost sharing.  

CMS said the mandate removes barriers to COVID-19 diagnostic testing and vaccinations.

In addition, the guidance confirms that plans and issuers must cover point-of-care COVID-19 diagnostic tests and COVID-19 diagnostic tests administered at state-administered or locally administered testing sites. 

THE LARGER TREND

The guidance is in accordance with the executive order President Biden signed on January 21. 

Through previous guidance and rulemaking, the departments addressed coverage requirements for COVID-19 vaccines and diagnostic testing in an interim final rule and FAQs Part 42 and FAQs Part 43.

Today's announcement further expands upon and clarifies these policies. 

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com