Must Cover “Medically Appropriate” Tests Only
The rapid rollout in March of the federal FFCRA (Families First Coronavirus Response Act) and CARES (Coronavirus Aid, Relief and Economic Security Act) Acts – and specifically section 6001 of the FFCRA, which defines requirements for insurers – has left providers, labs and insurers uncertain, at times, of their respective responsibilities for COVID-19 testing.
On June 23, the Trump administration offered additional clarification. Of particular note in the new joint guidance from the Departments of Health and Human Services (HHS), Treasury and Labor is clarification that insurers are not required to pay for tests not deemed “medically appropriate.” One of the biggest questions, as employers gradually reopen workplaces and institute mandatory testing, has been who is responsible for the costs of workplace testing.
Specifically, the guidance states:
“Is COVID-19 testing for surveillance or employment purposes required to be covered under section 6001 of the FFCRA?"
No. Section 6001 of the FFCRA requires coverage of items and services only for diagnostic purposes as outlined in this guidance. Clinical decisions about testing are made by the individual’s attending health care provider and may include testing of individuals with signs or symptoms compatible with COVID-19, as well as asymptomatic individuals with known or suspected recent exposure to SARS-CoV-2, that is determined to be medically appropriate by the individual’s health care provider, consulting CDC guidelines as appropriate.
However, testing conducted to screen for general workplace health and safety (such as employee “return to work” programs), for public health surveillance for SARS-CoV-2, or for any other purpose not primarily intended for individualized diagnosis or treatment of COVID-19 or another health condition is beyond the scope of section 6001 of the FFCRA.
The report offers further clarification on what constitutes an “individual’s health care provider,” noting that the provider deeming a test medically appropriate does not need to be “directly” responsible for the person’s care. He or she need only be a licensed provider who makes an “individualized clinical assessment” that the test is medically appropriate.
Also of note is that the law does not limit the number of tests any one individual can have covered by insurance “provided the tests are diagnostic and medically appropriate for the individual.” It also directly states that self-insured group health plans must comply with the law’s requirements.
In all, the report addresses 18 questions related to administration of the federal FFCRA and CARES Acts tackling such topics as what costs and which tests must be covered, determining billing rates, application of the law for in- and out-of-network visits, and how to manage overlapping state and federal requirements.
How QUADAX is Tackling COVID Reimbursement within the Revenue Cycle
As experts in reimbursement, we’ve developed a number of tools to help our clients navigate the uncertainty around COVID-19 reimbursement rules. Customers have access to analytic dashboards, benchmarks and payer intelligence support that are kept up to date on the latest information on a payer by payer basis. We have also created a custom scope of work tied to specific pricing that enables us to support labs with COVID testing, especially those labs that have received FDA EUA (Emergency Use Authorization) to perform COVID testing.
Contact us to learn more.