Policy, Payers

CMS rule requires insurers to cover tests for asymptomatic patients

A new CMS rule would require insurers to cover Covid-19 tests, even for asymptomatic patients. It builds on previous legislation requiring payers to cover the cost of both testing and vaccines for their members.  

As the Food and Drug Administration OKs more Covid-19 tests for asymptomatic patients, the Biden Administration is bolstering requirements for insurers to cover them. The Centers for Medicare and Medicaid Services issued guidance on Friday clarifying that health plans can’t deny coverage for Covid-19 tests, including for patients without symptoms or any known exposure.

Passed in March, the Families First Coronavirus Response Act required insurers to cover the cost of Covid-19 testing without any cost-sharing, such as copays or deductibles, or prior authorization requirements. These requirements applied to all health plans, including self-insured companies. But it only required insurers to cover the cost of tests “when medically appropriate for the individual,” as determined by a provider.

Now, health plans can’t use medical screening criteria to deny coverage for asymptomatic patients, CMS clarified.

“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,” the agency stated in a news release.

However, insurers still don’t have to cover worksite testing or tests for public health surveillance, according to the guidance.

“This really does apply for individuals seeking testing rather than broad-scale worksite testing,” said Sara Collins, vice president of health care coverage and access for the Commonwealth Fund.

Despite previous requirements that insurers cover the cost of Covid-19 tests, some patients were still stuck with a bill. Patients who got tested at emergency rooms sometimes faced facility fees, in spite of requirements that insurers cover costs related to the test and that providers don’t balance bill patients for Covid-19 related care.

CMS also reminded healthcare providers that they can get reimbursed for administering Covid-19 vaccines to patients without insurance through the CARES Act provider relief fund. As a preventive service, the vaccines must be covered according to the Affordable Care Act, though this was reiterated when the CARES Act was passed in March.

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