Ahead of an upcoming road trip with her elderly parents, Wendy Epstein’s doctor agreed it would be “safe” for her and her children to get tested for COVID-19.
Regarding the tests as a “medical need,” the doctor said insurance would likely pay them at no cost to Epstein. But her children’s pediatrician said the test would count as a screening test – since the children were not showing symptoms – and that she would likely have to foot the bill herself.
It made no sense. “These are two different answers for the exact same scenario,” said Epstein, professor of health law at DePaul University in Chicago, who postponed testing as she clarified the options.
At the start of the coronavirus pandemic – when the few COVID tests were limited to those with severe symptoms or severe exposure – the government and insurers promised that the tests would be provided free of charge (no copay, deductible or other expense) to ensure that those who need it have easy access.
Now those promises are being rescinded in a way that creates turmoil for consumers, even as testing has grown and more people – like Epstein – are urged to get them.
At the end of last month, the Trump administration released orientation saying insurers should waive patient fees only for “medically appropriate” tests “intended primarily for the diagnosis or individualized treatment of COVID-19.” He made it clear that insurers do not have to give up entirely on cost-sharing for drug testing, even when it is required for employees who return to work or to participate in public health surveillance efforts.
It is unclear what situations like the one faced by Epstein – and others who call for a test to clean a child for summer camp or daycare. Public health officials have unanimously believed that widespread and readily available testing is essential for reopening businesses and schools and for society to get back on its feet.
But who should bear the costs of these tests – or any part of them – is an unresolved question.
Who pays when all employees have to take 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?
The issues may be compounded in some cities and states where testing is widely available at clinics or drive-thru centers. CityMD clinics in New York City charge insurers $ 300 for the service, according to a patient benefit explanation document provided to KHN. The related cost of the laboratory that processed the test, according to the same patient’s statement of insurance, was $ 55. Most patients do not have to pay a share of these amounts.
The clinic has a partnership with the city allowing anyone who wants a virus test to get one. However, no test is really free, because the laboratories invoice insurers or ask for reimbursement of government programs.
Until a recent spike in virus cases created long delays in many regions, some other regions have also adopted a testing approach for anyone who wants a test. While this is one way to get a picture of where the virus is spreading, it can also become a cash cow providing income to clinics and labs, as residents look for several ‘free’ tests after each exposure. potential.
In an email, a CityMD spokesperson would not say how much the clinic is reimbursed for the tests. Clinics do not charge for laboratory tests, she wrote, referring questions about these costs to the laboratories that process them.
Insurers will make judgments – likely on a case-by-case basis – on how they handle cost-sharing for drug tests under new guidelines from the Trump administration.
What is clear: Insurers have objected to demands that they waive any cost sharing for COVID workplace testing, noting that they do not do so for other testing efforts, such as drug testing programs. For now, insurers “will continue to pay for doctor-recommended tests,” Kristine Grow, spokesperson for AHIP, an industry group, wrote in an email to KHN.
But AHIP also sent a clear signal that it would not accept cost-sharing exemptions for workplace or public health screening efforts. Earlier this month, the organization lobbied federal lawmakers to include funding in the next stimulus package for public health surveillance and workplace testing programs – an estimated cost of between $ 6 billion and $ 25 billion a year in an earlier study commissioned by the group.
Evolving rules for free tests
Coronavirus relief legislation passed by Congress in March and April advice from the Trump administration implementing it, agreed that patients should not be forced to pay for COVID tests and “medically appropriate” treatment.
But as the pandemic has evolved and grown, the definition of that term has both broadened and become more fuzzy.
the Centers for Disaster Control and Prevention says the test is appropriate for people who fall into five broad categories, including those with suspected exposure and those who need to be tested for “public health surveillance purposes”, which he defines as checking for hot spots or trends in the disease.
“There’s certainly a disconnect between what public health experts recommend for testing and how it’s going to be paid for,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.
And tension is mounting 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 low-wage jobs, also cannot afford the costs of testing, especially if they are required regularly.
Among those waiting to find out if their insurance will cover the test, Enna Allen of Glencoe, Illinois, urged her au pair to take a test after the young woman’s trip to New Orleans. She was on a plane, after all, and New Orleans has its share of COVID cases.
“I wanted her to take a test before she went back to work with my kids,” Allen said.
As Allen called to find a testing site, she explained that the test was needed for the job – for someone with no symptoms. After some effort, she found a clinic that, for $ 275, offered a quick 15 minute test and said she would accept insurance from her au pair.
“I guess they [the insurer] will cover it unless I get an invoice in weeks, ”said Allen, who said she would pay her employee’s bill if that happened.
There is also a large gray area in deciding who should qualify for a free test after “suspected” exposure. What is a suspected exposure? Do you share a small office with an infected colleague? Participate in a demonstration? Or just live or visit the Sun Belt, where the spread of the community is accelerating?
“If the au pair went to a clinic and said she was just in New Orleans, and the doctor said it was risky enough to order a test, even though she had no symptoms , my advice reading is the health plan should cover it 100%, ”Corlette said.
However, a child who has been primarily housed at home and who needs a test before being admitted to summer camp would likely not meet the definition.
“It’s a different story because it’s harder to pretend there was exposure or potential exposure,” Corlette said. “In the end, there are many ways to interpret advice.”
Congress Democrats have accused the Trump administration in its new guidelines of “giving loopholes to insurance companies instead of providing people with the free tests they need.”
Insurers, patients and politicians have already locked their horns when drug tests were charged differently than those same tests for diagnostic purposes, as the limit is often not clear. Under the Affordable Care Act, for example, colonoscopy cancer screening is “free”, that is, no copayment from the patient. But if a polyp is found, doctors sometimes code the procedure as a diagnostic test, which can lead to hundreds, even thousands, of co-pays.
While vital, testing is expensive – or can be. Medicare reimburses up to $ 100 for the COVID test. In addition to this, there may also be costs associated with visiting the office or clinic. And the price is very variable on the private market, according to a report last week by KFF, the Kaiser Family Foundation. Prices ranged from $ 20 to $ 850 for a single test. (KHN is an independent editorial program of the foundation.)
Media reports have shown tests averaging $ 100, but some labs charge insurers thousands of dollars for each.
Without a copayment, many patients never learn how much their tests are actually costing their insurers, which could lead to overuse.
Additionally, when patients are completely cost free, test manufacturers, labs 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 pinch in the form of higher premiums.
Questioning the very different views of his doctors on whether his insurance would fully cover the costs, law professor Epstein called his insurer, which assured him that tests would be 100% covered at network providers with no quota or deductible, provided they have been coded correctly. The family will soon be tested and it looks like they’ve dodged a financial bullet. But Epstein warned in an email, “I don’t know how many insurers will maintain this policy.”