Federal guidance released June 23, 2020, clarified that group health plans and individual insurance coverage are not required to reimburse testing costs for public health surveillance or employment purposes.
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Since the passage of the Families First Coronavirus Response Act (FFCRA) on March 18, 2020, most people should not face costs for the COVID-19 test or associated costs.
Under the CARES Act, group health plans and individual insurance must cover COVID-19 testing with no cost-sharing or medical management requirements, “when medically appropriate for the individual, as determined by the individual’s attending healthcare provider.” When providers charge cash up front, it falls to the patient to submit the bill to the health plan for reimbursement.
Under the CARES Act, comprehensive private health insurance plans must reimburse a test provider based on the rate negotiated between the plan and the provider (i.e., the in-network rate) that was put in place prior to this emergency.
If there is no negotiated rate between the plan and provider (i.e., the provider is out-of-network), the plan pays the provider based on the provider’s own “cash price” (or a lower price if the plan can negotiate one). This “cash price” must be posted online while there is a declared public health emergency. Providers that fail to make their price public could face a civil monetary penalty of up to $300/day.
Congress earmarked dollars within provider relief funds for testing and treatment for uninsured and created new Medicaid COVID-19 testing eligibility group that can be implemented as state option; states receive a 100 percent funding match. The new Medicaid eligibility category covers diagnostic testing, testing-related services, antibody tests; however, Kansas did not adopt this new eligibility criteria.
Yes, the Families First Coronavirus Response Act (FFCRA) relief fund contains $2 billion for provider reimbursement for COVID-19 testing of uninsured individuals. Providers are able to submit claims through a portal managed by the Health Resources and Services Administration (HRSA) in order to receive reimbursement equal to Medicare rates
This is unclear. For example, what about the individual who has had a contact with someone diagnosed with COVID-19 – does that meet the standard of medically appropriate? Should testing for this person be part of a state’s public health contact tracing and testing, which is outside the scope of health insurance coverage? Who will pay for tests? Is it the direct responsibility of individual employers or can federal funds allocated to states for their public health efforts be used for employment testing?
Although there is not clear consensus on who should be paying for workplace screening for employees not deemed “essential," most legal and policy experts suggest that employers or the federal government are responsible for providing workplace screening tests. Learn more from the Society for Human Resource Management (SHRM) and the Equal Employment Opportunity Commission (EEOC)
Kansans should be aware there may be bad actors looking to take advantage of people during the pandemic. If you experience healthcare-related price gouging, unexpected costs or something just doesn’t sound right with your costs or billing, please call the Kansas Insurance Department’s Consumer Assistance Division at 800-432-2484 or file a complaint on their website or by email.