FAQ 44 Clarifies Health Plan Coverage of COVID-19 Tests

Section 6001 of the Families First Coronavirus Response Act (FFCRA) had stipulated that COVID-19 testing and services must be covered “when medically appropriate for the individual, as determined by the individual’s attending health care provider.”  As discussed in FAQ guidance part 43 under Q&As 4 and 5, this includes at-home testing but would not include general COVID-19 testing for general screening purposes (e.g., tests requested or required by an employer rather than tests determined medically appropriate by the individual’s attending health care provider).

On Friday, February 26, 2021, new FAQ guidance part 44 now clarifies that health plans cannot use “medical screening criteria to deny (or impose cost sharing on) a claim for COVID-19 diagnostic testing for an asymptomatic person who has no known or suspected exposure to COVID-19.” The plan “cannot require the presence of symptoms or a recent known or suspected exposure, or otherwise impose medical screening criteria on coverage of tests. When an individual seeks and receives a COVID-19 diagnostic test from a licensed or authorized health care provider, or when a licensed or authorized health care provider refers an individual for a COVID-19 diagnostic test, plans and issuers generally must assume that the receipt of the test reflects an “individualized clinical assessment” and the test should be covered without cost sharing, prior authorization, or other medical management requirements.”  Practically speaking, this will make it tougher for a health plan to deny (or to impose cost sharing) on a test conducted by a health care provider at the request of an employer as allowed under the rules, as the health plan “must assume” any test conducted by a health care provider and billed to the plan is for a medical reason, not an employment screening reason.

The FAQ goes on to explain that “State and local public health authorities retain the authority to direct providers to limit eligibility for testing based on clinical risk or other criteria to manage testing supplies and access to testing. Responsibility for implementing such state or local limits on testing falls on attending health care providers, not on plans and issuers.”  Should a health plan observe a particular provider overcharging for testing, they advise that such “Plans and issuers that identify providers that are violating the cash price posting requirements should report violations to COVID19CashPrice@cms.hhs.gov.”

IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information.

This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.