Biden Admin reaffirms Covid testing must be covered without cost-sharing

March 1, 2021

CMS issued guidance Friday reminding providers and insurers that almost all instances of Covid-19 diagnostic testing must be covered without cost-sharing obligations for patients throughout the duration of the Public Health Emergency.

The guidance comes on the heels of an executive order signed by President Biden in January that strengthened and reaffirmed several portions of the CARES Act and Family First Coronavirus Response Act (FFCRA). Specifically, it states that insurers cannot use medical screening criteria to deny or impose cost-sharing requirements on a patient who receives a Covid-19 test, even if that person is asymptomatic.

“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,” CMS said in its FAQ.

This includes drive-thru sites or other state or locally administered test sites, which should significantly expand the types of testing that can be billed to insurers. 

However, this may not be the clarification many were seeking as the FAQ goes on to specifically state insurers are still allowed to distinguish between testing for individualized diagnosis or treatment as opposed to testing for workplace screening or public health surveillance. In those instances, CMS said insurers are not required to provide coverage, although they are not prohibited from doing so, either.

“However, plans and issuers are not required to provide coverage of testing such as for public health surveillance or employment purposes. But there is also no prohibition or limitation on plans and issuers providing coverage for such tests,” CMS said. “Plans and issuers are encouraged to ensure communications about the circumstances in which testing is covered are clear.”

The FAQ also outlines that approved vaccines must be covered without cost-sharing and reminds labs who are providing Covid testing of the potential penalties of not posting their test cash price online.

So, what changes? Perhaps this will slow down the trend of insurance plans not paying for individual Covid testing and forcing co-pays or deductibles to their enrollees. What this doesn’t seem to do is give blanket coverage for all workplace screening tests to be paid without medical necessity and documentation. 

On an individual basis, CMS has clarified all tests are covered and cannot be denied or balanced billed. Yet, this does not give cart-blanche coverage for all screening tests performed. While this may not be the crystal clear guidance many were hoping for, it is at least a step in the right direction in terms of clarifying exactly when a test must be covered.

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