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

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