In accordance with the Executive Order President Biden signed on January 21, 2021, the Centers for Medicare & Medicaid Services (CMS), together with the Department of Labor and the Department of the Treasury, (collectively, the Departments) issued new guidance today removing barriers to COVID-19 diagnostic testing and vaccinations and strengthening requirements that plans and issuers cover diagnostic testing without cost sharing.
This guidance makes clear that private group health plans and issuers generally cannot use medical screening criteria to deny coverage for COVID-19 diagnostic tests for individuals with health coverage who are asymptomatic, and who have no known or suspected exposure to COVID-19. Such testing must be covered without cost sharing, prior authorization, or other medical management requirements imposed by the plan or issuer. For example, covered individuals wanting to ensure they are COVID-19 negative prior to visiting a family member would be able to be tested without paying cost sharing. The guidance also includes information for providers on how to get reimbursed for COVID-19 diagnostic testing or for administering the COVID-19 vaccine to those who are uninsured.
This announcement clarifies the circumstances in which group health plans and issuers offering group or individual health insurance coverage must cover COVID-19 diagnostic tests without cost sharing, prior authorization, or other medical management requirements to include tests for asymptomatic individuals without known or suspected exposure to COVID-19. In addition, the guidance confirms that plans and issuers must cover point-of-care COVID-19 diagnostic tests, and COVID-19 diagnostic tests administered at state or locally administered testing sites.
The Departments have received many questions about plan and issuer responsibility to cover COVID-19 diagnostic testing for individuals who are asymptomatic and have no known or suspected recent exposure to COVID-19. Today’s guidance clarifies that plans and issuers generally must cover, with no cost sharing, COVID-19 diagnostic tests regardless of whether the patient is experiencing symptoms or has been exposed to COVID-19 when a licensed or authorized health care provider administers or has referred a patient for such a test. Additionally, plans and issuers are prohibited from requiring prior authorization or other medical management for COVID-19 diagnostic testing.
This guidance also reinforces existing policy regarding coverage for the administration of the COVID-19 vaccine and highlights avenues for providers to seek federal reimbursement for costs incurred when administering COVID-19 diagnostic testing or a COVID-19 vaccine to those who are uninsured. One such existing program is through the Provider Relief Fund program, which has a separate effort for providers to submit claims and seek reimbursement on a rolling basis for COVID-19 testing, COVID-19 treatment, and administering COVID-19 vaccines to uninsured individuals (the HRSA COVID-19 Uninsured Program)  . The HRSA Uninsured Program has already reimbursed providers more than $3 billion for the testing and treatment of uninsured individuals, and expects to see vaccine administration claims as states scale up their vaccination efforts. To further build awareness about the availability of this program, this announcement seeks comment on strategies to connect those without insurance to care from providers participating in this fund.
Through previous guidance and rulemaking, the Departments addressed coverage requirements for COVID-19 vaccines and diagnostic testing in an interim final rule and FAQs Part 42 and FAQs Part 43. Today’s announcement further expands upon and clarifies these policies. For more information on issuer and provider vaccine coverage and reimbursement requirements, the CMS toolkit is available here.
The guidance issued today can be viewed here: https://www.cms.gov/files/document/faqs-part-44.pdf
For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies Website.