How do you know if your insurance covers covid test

Before an upcoming road trip with her elderly parents, Wendy Epstein’s doctor agreed it would be “wise” for her and her children to get tested for COVID-19.

Seeing the tests as a “medical necessity,” the doctor said insurance would likely pay for them, at no out-of-pocket cost to Epstein. But her children’s pediatrician said the test would count as a screening test, since the children had no symptoms, and that she would probably have to foot the bill herself.

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It didn’t make sense. “Those are two different answers to the exact same scenario,” said Epstein, a health law professor at Paul University in Chicago, who deferred testing while she clarified options.

Early in the coronavirus pandemic, when scarce covid testing was limited to those with severe symptoms or severe exposure, the government and insurers promised that testing would be administered free of charge (with no copays, deductibles, or other fees). pocket-size). expenses) to ensure those in need had immediate access.

Now, those promises are being reversed in a way that is creating confusion for consumers, even as testing has become more plentiful and more people, like epstein, are being advised to get tested.

late last month, the trump administration issued guidance saying insurers had to waive patient costs only for “medically appropriate” tests “primarily intended for the individualized diagnosis or treatment of covid-19 “. made it clear that insurers do not have to waive cost-sharing for screening tests entirely, even when they are required for employees returning to work or to assist in public health surveillance efforts.

Situations like the one faced by epstein, and others seeking proof to clear a child for summer camp or daycare, remain unclear. public health officials have been unanimous in their opinion that widespread and readily available testing is crucial for businesses and schools to reopen, and society to recover.

but who should bear the costs of those tests, or a part of them, is an open question.

who pays when all employees must have a negative covid test to return to work? or if a factory tests workers every two weeks? or just because someone wants to know for their own peace of mind?

Questions can get complicated in some cities and states where testing is widely available at clinics or drive-through centers. in new york, citymd clinics bills insurers $300 for the service, according to an explanation of benefits document given to khn by a patient. the related charge from the lab that processed the test, according to the same patient’s insurance statement, was $55. most patients do not have to pay a portion of these amounts.

The clinic has a partnership with the city that allows anyone who wants to get tested for the virus to get tested. Still, no test is truly free, as labs bill insurers or seek reimbursement from government programs.

Until a recent spike in virus cases led to long delays in many areas, some other regions also adopted a test-for-everyone who wants a test approach. While that’s one way to get a sense of where the virus is spreading, it can also become a source of income, providing income to clinics and labs as residents seek out multiple “free” tests after each potential exposure.

In an email, a citymd spokesperson did not say how much the clinic is reimbursed for testing. clinics don’t charge for lab tests, he wrote, referring questions about those costs to the labs that process them.

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Insurers will make decisions, likely on a case-by-case basis, about how they will handle cost-sharing for screenings under the new guidance from the trump administration.

What’s clear: Insurers have opposed requirements to waive all cost-sharing for workplace COVID testing, noting they don’t for other screening efforts, such as testing programs of drugs. For now, insurers “will continue to pay for doctor-recommended tests,” Kristine Grow, a spokeswoman for ahip, an industry group, wrote in an email to Khn.

but ahip also sent a clear signal that it would not adopt cost-sharing waivers for public health or workplace screening efforts. Late last week, the organization pressed federal lawmakers to include funding in the next stimulus package for public health surveillance and workplace testing programs, estimated to cost between $6 billion and $25 billion annually in an earlier study commissioned by the group.

the evolving rules for free trials

Coronavirus relief legislation passed by Congress in March, and April guidance from the Trump administration to implement it, agreed that patients should not be burdened with payments for “medically appropriate” Covid testing and treatment.

but as the pandemic has evolved and grown, the definition of that term has become broader and more confusing.

The Centers for Disease Control and Prevention say testing is appropriate for people who fall into five broad categories, including those with suspected exposure and those who should be tested for “infection surveillance purposes.” public health”, which he defines as the detection of disease hot spots or trends.

“There is definitely a disconnect between what public health experts recommend for testing and how it will be paid for,” said Sabrina Corlette, co-director of the Center on Health Insurance Reform at Georgetown University.

And it increases tension between insurers, employers and consumers over who should pay. While insurers say employers should cover the cost of back-to-work testing, many employers are struggling financially and may not be able to do so. At the same time, workers, especially those in lower-wage jobs, also cannot afford the out-of-pocket costs of testing, especially if it is required regularly.

Among those waiting to find out if their insurance will cover the test is enna allen of glencoe, illinois, who urged her au pair to get tested after the young woman traveled to new orleans. She had been on a plane, after all, and New Orleans has her share of Covid cases.

“I wanted him to get tested before I went back to work with my kids,” Allen said.

when allen called to find a testing site, he explained that the test was required for employment, for someone without symptoms. After some effort, she found a clinic that, for $275, offered a quick 15-minute test and said she would accept her au pair’s insurance from her.

“I guess they [the insurer] will cover it unless I get a bill in a few weeks,” said Allen, who said he would pay his employee’s bill if that happens.

There is also a big gray area when deciding who should qualify for the free trial after a “suspicious” exposure. what is suspected exposure? Sharing a small office with an infected co-worker? participate in a protest? or just live or visit the sun belt, where community spread is accelerating?

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“if the au pair went to a clinic and said she’s just been to new orleans, and the doctor said she’s risky enough to order a test, even though she has no symptoms, my guideline reading is plan to health has to cover it 100 percent,” corlette said.

However, a child who has primarily sheltered at home and needs proof before being admitted to summer camp would likely not meet the definition.

“That’s a different story because it’s more difficult to argue that there has been exposure or potential exposure,” Corlette said. “At the end of the day, there are many ways to interpret the guide.”

Congressional Democrats have accused the trump administration in its new guidance of “giving insurance companies loopholes instead of giving people the free tests they need.”

Insurers, patients, and politicians have clashed before when screening tests have been billed differently from the same tests for diagnostic purposes, as the cutoff is often unclear. Under the Affordable Care Act, for example, cancer screening colonoscopy is “free,” meaning there is no co-payment by the patient. But if a polyp is found, doctors sometimes code the procedure as a diagnostic test, which can lead to copays of hundreds or even thousands of dollars.

While vital, the test is expensive, or can be. medicare reimburses up to $100 for the covid test. On top of that, there may also be costs associated with the office or clinic visit. and the price is highly variable on the private market, according to a report released this week by kff, the kaiser family foundation. prices ranged from $20 to $850 for a single test. (khn is an editorially independent program of the foundation).

Media reports have shown tests averaging $100, but some labs bill insurers thousands of dollars for each test.

Without a copay, many patients never know how much their tests actually cost their insurers, which could lead to overuse.

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In addition, when patients are fully shielded from cost, test manufacturers, laboratories and medical providers are more likely to seek price increases, said Heather Meade, director of the Washington Council Ernst & young.

In the end, consumers may still feel a resulting pinch in the form of higher premiums.

Wondering about her doctors’ markedly different views on whether her insurance would cover the full cost, law professor epstein called her insurer, who assured her that the tests would be covered 100 percent at in-network providers. no copay or deductible, as long as they are coded correctly. The family will soon be put to the test and it appears that he has dodged a financial bullet. But Epstein warned in an email: “I’m not sure how many insurers will carry this policy.”

khn (kaiser health news) is a non-profit news service covering health topics. It is an editorially independent program of KFF (Kaiser Family Foundation) which is not affiliated with Kaiser Permanente.

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