COVID 19 Testing Health Insurance Coverage Explained

 

Should my COVID-19 Test be Free?

At this point, nearly everyone has either had a COVID-19 test or knows someone who has dealt with testing procedures.  As expected, there have been some difficulties along the way.  Some people are paying hundreds of dollars out of pocket while others pay nothing.  This post focuses on people with employer-sponsored health insurance and addresses a question we hear constantly: “Why isn’t my test being covered?”

First and foremost, if the provider you use does not accurately submit a claim to the health insurer, you can expect the claim to be paid incorrectly.  Their accuracy could be based on the data you give them.  In fact, there are some providers who do not submit to insurance at all.  In this case, you should expect to pay their rate for the testing. (However,  they may not even bill you, stating that the federal government will cover it.)  The bottom line on this topic is that you have to be a careful consumer and ask questions.

Here are a few general guidelines on current coverage of testing, based on data through January 27, 2021.

• Carriers will cover the rapid or PCR test at 100% with no cost to you if their guidelines are met. Guidelines include:
  • The member has been exposed to COVID and/or;
  • The member has clinical COVID symptoms; and, most importantly,
  • Claims submitted by providers/labs/pharmacy meet carrier billing and submission guidelines.
• Asymptomatic testing is generally covered at 100% if the individual:
  • Has known or suspected exposure to a confirmed case of COVID;
  • Is being tested for pre-admission or pre-surgical purposes;
  • Is immunocompromised;
  • Results of testing will impact medical care; or
  • Is receiving an aerosol-generating procedure (for instance, intubation).
• Carriers will cover the diagnostic antibody test with no cost to the member “when medically necessary” through April 21, 2021, as long as it is appropriately billed in accordance with COVID-19 billing guidelines.
• The two currently authorized vaccines are from Pfizer-BioTech and Moderna. Health plans pay 100% of the cost of administration of the vaccine.  Thus, the customer out-of-pocket cost for the COVID-19 vaccine, through all legitimate distribution channels, will be $0.

The best advice I can give anyone using their health insurance is to be a savvy consumer.  If something does not make sense, question it.  If you are not sure of the cost prior to a procedure or test, ask your provider!

 

Video Transcription:

All right guys, it’s happened again. We’ve got more confusion going on with COVID testing and how it should be covered in all this. In fact, we just had an employee get charged $300 to get a COVID test for their child when it should have been free. At the end of the day, it’s the wild West out there. And what we did is we went ahead and created a voiceover PowerPoint. We’re going to give it to anyone that needs it. Hopefully, it’s helpful to you or, or some of your employees. There’s a link in this post to it. If you have any questions, feel free to shoot me a note here on LinkedIn, or, or give me an email at [email protected]. I hope this is helpful. It’s a huge pain point for folks out there. So get yourself educated and again, let me know of any questions.

 

Nick Hendricks
Consultant

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Phone: 678.904.9336