CMS moves to stop COVID-19 testing denials, cost sharing in private plans

Dive Brief:

CMS has issued guidance to stop private group health plans from denying COVID-19 testing through the use of medical screening criteria for asymptomatic individuals with insurance coverage.
Congress required comprehensive health plans to cover COVID-19 tests without cost sharing, prior authorization or medical management last year, only for guidance to create uncertainty about the rules. President Joe Biden sought to clarify the situation in an executive order shortly after taking office.
CMS has built upon the order with guidance that details when testing needs coverage. ACLA, a laboratory trade group representing Quest Diagnostics and LabCorp, praised the move as "decisive action" that takes "critical steps to close coverage gaps" and protect patient access to COVID-19 testing.

Dive Insight:

The rules on coverage of COVID-19 testing have been a point of tension between health insurers and out-of-network test providers, which have traded blame for reports of high prices and gaps in coverage.

The American Clinical Laboratory Association wrote to Biden last week to call for the closing of testing coverage loopholes.

Days later, CMS published guidance that answers a series of questions about the implementation of legislation passed by Congress last year. The guidance states plans and issuers cannot use "medical screening criteria to deny (or impose cost sharing on) a claim for COVID-19 diagnostic testing for an asymptomatic person who has no known or suspected exposure to COVID-19." CMS said the unequivocal statement clarifies an older declaration about asymptomatic testing.

The confusion arose from CMS' position on the coverage of testing for surveillance or employment purposes. Such screening is excluded from the legislative requirement to cover COVID-19 tests. Yet, in explaining that exclusion CMS introduced confusion about the coverage of asymptomatic people. The new guidance separates out surveillance and employment tests to clarify the situation.

Other parts of the new document state that insurers have to cover point-of-care tests and COVID-19 diagnostic tests provided through state- or locality-administered sites. No cost sharing is permitted.

America's Health Insurance Plans, which represents insurers including Aetna and Anthem, also commented on the guidance.

"Since the beginning of the COVID-19 crisis, health insurance providers have worked with hospitals, health providers, and others to ensure that Americans have access to the prevention, testing, and treatment needed to overcome COVID-19, and that cost is not a barrier. Working together, we must expand and increase COVID-19 testing," AHIP spokesperson David Allen said.

In the past, the group has accused out-of-network labs of price gouging.