CMS Requires Health Plans To Pay For Diagnostic COVID-19 Tests

March 3, 2021

 

In response to tremendous confusion as to whether patients can be required to pay any amount “out of pocket” for COVID-19 tests, CMS clarified prior guidance as follows:

  • Health plans must provide coverage for diagnostic testing of COVID-19 regardless of whether individuals present with symptoms or have a recent known or suspected exposure. Health plans are not required to provide coverage for public health surveillance or employment purposes but are not prohibited from doing so.
  • The requirements for coverage apply to health plans offering group or individual health insurance coverage, including self-insured health plans.
  • Health plans cannot impose cost sharing or prior authorization requirements.
  • These requirements apply to both PCR and point-of-care (“rapid”) testing.
  • Health plans must reimburse providers of COVID-19 diagnostic tests in an amount that equals the provider’s negotiated rate or, for an out-of-network provider, the cash price for such service that is listed on the out-of-network provider’s website.
  • Providers (g., laboratories, including physician office laboratories and pharmacies performing rapid testing) must list their fees for testing on their websites.
  • Health plans must cover, without cost sharing, all COVID-19 recommended vaccines and their administration.

This means that all entities that offer COVID-19 diagnostic testing will need to review their current procedures to ensure that patients with insurance coverage are not required to pay out of pocket for the COVID-19 testing or recommended vaccinations, unless the testing is for employment or surveillance purposes.  Furthermore, the entities that actually perform the COVID-19 diagnostic tests will need to post their fees on their website.

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For questions or assistance in adjusting your current procedures or to prepare your website posting, please contact the Garfunkel Wild attorney with whom you regularly work, or contact us at info@garfunkelwild.com.

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