In advance of an upcoming road trip with her elderly parents, Wendy Epstein’s physician agreed it would be “prudent” for her and her kids to get tested for Covid-19.
Seeing the tests as a “medical need,” the doctor said insurance would likely pay for them, with no out-of-pocket 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 she would probably have to foot the bill herself.
It made no sense. “That’s two different responses for the exact same scenario,” said Epstein, a health law professor at DePaul University in Chicago, who deferred the tests as she clarified the options.
Early on in the coronavirus pandemic — when scarce Covid testing was limited to those with serious symptoms or serious exposure — the government and insurers vowed that tests would be dispensed for free (with no copays, deductibles or other out-of-pocket expense) to ensure that those in need had ready access.
Now, those promises are being rolled back in ways that are creating turmoil for consumers, even as testing has become more plentiful and more people — like Epstein — are being advised to get them. (In Flagler County, testing remains free at the Flagler Health Department, at the Daytona State College site–which moves to Cattleman’s Hall at the county fairgrounds starting on July 27, with longer hours–and at four other sites run by the health department, listed at the bottom of this article.)
Late last month, the Trump administration issued guidance saying insurers had to waive patient costs only for “medically appropriate” tests “primarily intended for individualized diagnosis or treatment of Covid-19.” It made clear that insurers do not have to fully waive cost sharing for screening tests, even when required for employees returning to work or for assisting in public health surveillance efforts.
Left unclear are situations like that faced by Epstein — and others who seek a test to clear a child for summer camp or day care. Public health officials have been unanimous in the opinion that widespread, readily available testing is crucial for getting businesses and schools open again, and society back on its feet.
But who should bear the costs of that testing — or a share of them — is an unresolved question.
Who pays when all employees are required to have a negative Covid test in order 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 questions may be compounded in some cities and states where tests are widely available at clinics or drive-thru centers. In New York, CityMD clinics bill insurers $300 for the service, according to an explanation-of-benefits document given to KHN by a patient. The related charge from the lab that processed the test, according to the same patient’s insurance statement, was $55. Most patients don’t have to pay a share of those amounts.
The clinic has a partnership with the city allowing anyone who wants a test for the virus to get one. Still, no test is truly free, as labs bill insurers or submit for reimbursement from government programs.
Until a recent spike in virus cases created long delays in many areas, some other regions also took a test-everyone-who-wants-a-test approach. While that 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 seek multiple “free” tests after each potential exposure.
In an email, a spokesperson for CityMD would not say how much the clinic is reimbursed for testing. The clinics do not bill for lab testing, she wrote, referring questions about those costs to the laboratories that process them.
Insurers will be making judgment calls — likely on a case-by-case basis — about how they will handle cost sharing for screening tests under the new Trump administration guidance.
What is clear: Insurers have argued against requirements that they waive all cost sharing for workplace COVID testing, noting they don’t do that for other screening efforts, such as drug-testing programs. For now, insurers will “continue to pay for tests recommended by a doctor,” 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 embrace cost sharing waivers 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 — a cost estimated between $6 billion and $25 billion annually in an earlier study commissioned by the group.
The Evolving Rules for Free Testing
The coronavirus relief legislation passed by Congress in March, and April guidance from the Trump administration implementing it, agreed that patients should not be burdened with payments for Covid testing and treatment that is “medically appropriate.”
But as the pandemic has evolved and grown, the definition of that term has both broadened and become fuzzier.
The Centers for Disease Control and Prevention says testing is appropriate for people who fall into five broad categories, including those with suspected exposure and those required to be tested for “purposes of public health surveillance,” which it defines as checking for disease hot spots or trends.
“There’s definitely a disconnect between what public health experts are recommending 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 among insurers, employers and consumers over who should pay. While insurers say employers should cover the cost for 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 lower-wage jobs, also cannot afford out-of-pocket costs for testing, particularly if it is required regularly.
Among those waiting to hear if their insurance will cover the test is Enna Allen of Glencoe, Illinois, who urged her au pair to get a test after the young woman traveled to New Orleans. She had been on a plane, after all, and New Orleans has its share of Covid cases.
“I wanted her to have a test before she returned to work with my kids,” said Allen.
As Allen called around to find a testing site, she explained the test was needed for employment — for someone with no symptoms. After some effort, she found a clinic that, for $275, offered a 15-minute rapid test and said it would accept her au pair’s insurance.
“I’m assuming they [the insurer] will cover it unless I get a bill weeks from now,” said Allen, who said she would pay the bill for her employee if that happens.
There is also a great gray area in deciding who should qualify for free testing after “suspected” exposure. What is suspected exposure? Sharing a small office with an infected co-worker? Participating in a protest? Or simply living in or visiting the Sun Belt, where community spread is accelerating?
“If the au pair went to a clinic and said she was just in New Orleans, and the doctor said that’s enough of a risk to order a test, even though she doesn’t have symptoms, my read of the guidance is the health plan has to cover it 100%,” said Corlette.
Yet a child who’s mainly been sheltering at home who needs a test before being admitted to summer camp probably would not meet the definition.
“That’s a different story because it’s harder to argue there’s been exposure or potential exposure,” said Corlette. “At the end of the day, there’s many ways to interpret the guidance.”
Congressional Democrats have accused the Trump administration in its new guidance of “giving insurance companies loopholes instead of getting people the free testing they need.”
Insurers, patients and politicians have locked horns before when screening tests were billed differently than those same tests for diagnostic purposes, since the boundary is often unclear. Under the Affordable Care Act, for example, colonoscopy screening for cancer is “free,” meaning no patient copayment. But if a polyp is found, doctors sometimes code the procedure as a diagnostic test, which can lead to hundreds or even thousands of dollars in copayments.
While vital, testing is costly — or can be. Medicare reimburses up to $100 for the Covid test. On top of that, there may also be costs associated with the office or clinic visit. And the price is widely variable in the private market, according to a report out last week by KFF, the Kaiser Family Foundation. Prices ranged from $20 to $850 for a single test. (KHN is an editorially independent program of the foundation.)
Media reports have shown tests average $100, but some labs bill insurers for thousands of dollars for each one.
Without a copay, many patients never learn how much their tests actually cost their insurers, which could lead to overuse.
Also, when patients are entirely shielded from the cost, test makers, labs and medical providers are more likely to seek price increases, said Heather Meade, a principal at Washington Council Ernst & Young.
In the end, consumers may still feel a resulting pinch in the form of higher premiums.
Wondering about the sharply different views of her doctors on whether her insurance would fully cover the cost, law professor Epstein called her insurer, which assured her the tests would be covered 100% at in-network providers with no copay or deductible, as long as they were coded correctly. The family will be tested soon, and it appears she’s dodged a financial bullet. But Epstein cautioned in an email: “It’s unclear to me how many insurers will maintain this policy.”
–Julie Appleby, Kaiser Health
Taxpayers pay for testing ,period! Another way for government officials to scatter money around to sheep companies who go along with their plan.
Percy's mother says
Unless insurance pays, people don’t want to take care of their health, regardless of necessity.
I had a female patient back in 2012 (will never forget this). A very wealthy woman. Penthouse on the beach. Had just come back from a one year around-the-world trip. A business owner. She came to see me. She really needed help. I suggested she would need 3 x-rays, which Medicare would not pay for. Total bill would have been $100.00.
The woman refused to pay $100.00 out of pocket for the 3 imaging studies she desperately needed. She tried to get me to participate in insurance fraud. I ended up discharging this very wealthy woman via certified letter.
The above was / is not uncommon. People have been conditioned that health insurance should pay for everything.
People can keep buying cigarettes, booze, garbage food, cell phones, waste money on multiple other unnecessary things, go on trips, buy rental properties, go into debt for cars well beyond their means, etc., but DO NOT WANT TO PAY ANYTHING OUT OF POCKET FOR THEIR HEALTH. They even whine about a co-pay for God’s sake.
As far as I’m concerned, if it has to do with my health, I’ll pay out of pocket. I don’t whine about it or claim to be a victim of the healthcare system. Healthcare should be a priority with everything else coming afterwards.
I agree with you 100%. After retiring from the U. S. Army, I had my own service business for 20 years. Many times I experienced the same situation. They wanted an issue to be resolved immediately and after doing so, they whined about the bill, even after they were informed of the approximate price. In most cases, this occurred with people that were well off financially. Those kind situations finally help me to retire again. It was very frustrating.
The next phase of the healthcare non-solutions are who pays for testing now. The monthly premium needs to cover this just like it does for any flu. Why would anyone have to pay those $ 1K/month premiums and pay for this lab, when it’s inaccurate test kits & results you get back. And what kind of healthcare are you getting if you are truly positive ? The front end of Coronavirus was/is a scam of a grant to study something we have no vaccines nor cures for. All of this comes down to who profits. I read the wealthy patients want it covered, so why would the poorer masses want to pay if the wealthiest don’t. It’s not like the folks over at the $ 10-12/hour jobs get to raise their wages to cover the shortfalls of the income disparities in this world. They want products on shelves to sell, but don’t take care of those that actually do the work putting that product out in the middle of the nights. Leave others short and they can’t pay, it’s really basic math, racking up debt at the individual level really isn’t sustainable for anyone.
Reinhold Schlieper says
You mean to tell me that when our esteemed president told us that anyone who wants a test can get a test, he was lying? He probably meant that anyone who wants and can pay for or is rich enough to afford to or can finagle someone to pick up the tab for or subscribes to the Trump Care that will bring us cheaper and much simpler access to health care than by way of the Affordable Care Act, which he is trying to kill, of course–if all that is the case, then if the person can find a testing site that will take him/her in for a particular time, then s/he can get a test. But that would be too complicated a structure to place into a tweet, huh? Gotta forgive the guy; the English language is such a challenge.
European nations have been successful against the virus because of unrestricted and free testing. Not here, huh?