Is COVID-19 Testing of Employees Covered by Insurance? Answers to an often asked question.
Is COVID-19 Testing of Employees Covered by Insurance?
Answers to an often asked question.
We field calls just about every day asking whether employee testing is covered. There is no one good answer and the laws about what insurers have to pay and under what circumstances for are confusing.
Compounding the difficulty of answering the question is the fact that insurers are changing their policies on employee testing and whether testing is a covered service just about every month.
We’ve distilled some of the facts here for you and also provided extracts from the various laws relevant to whether insurers have to pay, along with information from the insurers themselves.
Are Insurance companies required to cover the cost of testing your insured employees?
If they are experiencing symptoms of COVID-19, yes. If they know or suspect they’ve been exposed to the virus, yes. But they are looking at the way the test is ordered and what the physician that orders the test notes as the reason for testing (the diagnosis code chosen) has an impact on whether the test is covered.
Physicians ordering the test must mark that the test is for "Contact with and (suspected) exposure to other viral communicable diseases," and use code Z20.828 in this scenario- one where exposure is suspected.
In that case- we have a suspected exposure or symptomatic employee/s- will insurers cover the cost of an On-Site COVID-19 Testing Service?
Generally, yes, but at a reimbursement rate the insurer sets and that rate may be less than a company providing the service is willing to accept. Also, insurance companies pay very slowly and require companies to submit time consuming paperwork.
So the issue is not necessarily whether the insurer will pay but whether you can find a company or healthcare provider willing and able to provide service per the insurers billing and payment rules.
Generally speaking, outpatient centers, clinics, hospitals and government-sponsored testing sites will accept insurance and test your employees individually without limit. On-site providers though, which is what we are, may be less willing to work with insurers because it costs much more for us to deliver our concierge-style services.
The difference is similar to having a chef come to your house with all the supplies and ingredients to make a meal in comparison to cooking for you at their restaurant. Unfortunately insurers do not pay any more for on-site services than they do to an urgent care.
What if my employees are not symptomatic and I just want to have them tested to ensure I keep the workplace safe and prevent possible spread of the virus?
If your employees are considered “Essential Workers” insurers have to pay for testing but they have the option, under the law to:
“offer an enrollee who is an “essential worker” a COVID-19 testing appointment that will take place within 48 hours of the enrollee’s request.” (full text of the law here)
That means you can count on insurers to pay for testing almost without limit and even have a policy requiring employees to get tested frequently (weekly is common). But bear in mind that insurers have the right to make your employees get tested at a clinic or testing site.
So, are insurers paying if I call a company like DHS to do testing or even ongoing testing just to ensure a safe workplace or not?
There is no one answer to this question. Sometimes yes and sometimes no, they are denying insurance claims seeking reimbursement for the cost of testing conducted by an on-site COVID-19 testing service. Lately we've seen claims denied for on-site testing and the only way to get a certain answer to this question is to work with your insurer, agent or producer prior to ordering an on-site service. They can typically tell you whether services will be paid for or if claims will be denied so you can make an informed decision.
This leads to a repeat of the statement above about testing companies and labs being unwilling to take the risk.
Some companies, ours included, will ask for payment from the client and then refund any amount paid by the insurer after the claim/s are paid. Some companies will not require prepayment but ask you to sign a contract guaranteeing payment in the case the insurer does not pay them or the rate they charge.
There are two national companies that heavily advertised "free" on-site testing and guaranteed clients would never have to pay because they could bill insurance or under the CARES Act without limit. For a time they were successful in delivering on their promise. Then in October insurers largely changed course and began to direct companies to clinics and testing sites. As a result we've seen those ads disappear and the companies now ask for payment to be guaranteed by the client.
You mentioned that insurers are changing their policies or the way they pay for employee COVID-19 testing every so often. Where do they stand today?
There was a Webinar put on by Vachette Pathology last week. Vachette is a well respected resource for labs across the country and they sounded the alarm in saying insurers will be denying employee testing claims and also taking money back for testing that does not meet a strict causal criteria.
What impact has this had on companies that provide employee COVID-19 testing services?
It has made us all much more cautious. Our company will only provide testing of Medicare recipients that live in congregant settings without requiring the client to pay because Medicare has been steady in covering testing of their aging population. We require all other companies to pay us out of pocket, and in return we guarantee we will remit any amount paid to us by an insurer.
Our lab partners have the same policy and are far less willing to risk accepting insurance as the payer without a guarantee by those tested or their employer.
Should we expect any change in insurer payment policies for employee testing?
Based on the trend we are seeing lately I would expect insurers to continue to push the appointment option and seek to avoid on-site services. Consider, insurance companies are obligated to care for the insured individual, not their employer. If a business is able to stay open because they require ongoing employee testing most insurers look at this as an operational cost that the business should bear. Especially because testing is being done proactively as opposed to suspected outbreak or infection.
Insurers are not in the business of assisting other businesses, even those that employ a large number of their insured. They are in the business of creating profit for shareholders while caring for their members. If an insurer can meet their responsibility to provide testing for their insured members without paying for pre-emptive testing, they will likely choose that option over supporting a company’s testing strategy.
Where I believe insurers will continue to support testing is when it is in response to an insured’s being symptomatic or suspected exposure. Otherwise expect to see insurers pushing for testing appointments as allowed by the law.
Links to the full text of relevant laws and extracts below:
From the CA Department of Managed Healthcare (full text here):
Access for enrollees (including “essential workers”) with symptoms of COVID-19 or known/suspected exposure to COVID-19*
Per federal law, an enrollee with symptoms of COVID-19 or who has known or suspected exposure to COVID-19 may access testing from any provider (in or out of network) without first going through the enrollee’s health plan.
Health plans must reimburse providers for COVID-19 tests administered to enrollees with symptoms of COVID-19 or known/suspected exposure to COVID-19, regardless of whether the enrollee received the test from an in-network or out-of-network provider.
A health plan may not limit the number or frequency of tests an enrollee receives when the enrollee has symptoms of COVID-19 or known or suspected exposure to COVID-19.
Access requirements for asymptomatic “essential workers” who do not have a known or suspected exposure to COVID-19*
The emergency regulation defines COVID-19 testing as medically necessary for enrollees who are “essential workers” regardless of whether the enrollee has symptoms of or suspected/known exposure to COVID-19.
Because testing is deemed to be medically necessary, health plans may not require prior authorization for testing of “essential workers”.
Accordingly, health plans must offer an enrollee who is an “essential worker” a COVID-19 testing appointment that will take place within 48 hours of the enrollee’s request. A health plan may not limit the number or frequency of tests an enrollee who is an essential worker receives.
Additionally, the appointment must be with a provider located within 30 minutes or 15 miles of the enrollee’s residence or workplace. If the plan does not offer the enrollee an appointment meeting these time and distance requirements, the enrollee may access a COVID-19 test from any available provider (whether in or out of network). In-network cost-sharing applies in such instances.
Access requirements for asymptomatic enrollees who are not “essential workers” and do not have a known/suspected exposure to COVID-19
The emergency regulation requires health plans to cover COVID-19 testing for enrollees who are not “essential workers” and who do not have symptoms of or exposure to COVID-19 when such testing is medically necessary.
As such, a health plan may impose prior authorization requirements on such testing. If the health plan requires prior authorization and finds the testing to be medically necessary for the enrollee, the plan must offer the enrollee an appointment for a COVID-19 test to occur within 96 hours of the enrollee’s request. The appointment for all other asymptomatic enrollees (who have had no exposure to COVID-19) must be with a provider located within 30 minutes or 15 miles of the
The emergency regulation allows health plans to charge ordinary cost-sharing for COVID-19 testing, unless otherwise provided by federal or state law. The federal FFCRA and the CARES Act require health plans to provide COVID-19 testing at zero cost-sharing for enrollees with symptoms of COVID-19 or known or suspected exposure to someone with COVID-19.
Accordingly, health plans must continue to impose no cost-sharing for COVID-19 testing for enrollees with symptoms of or known/suspected exposure to COVID-19. For all other enrollees (i.e., enrollees without symptoms of or known/suspected exposure to COVID-19), health plans may impose ordinary cost-sharing for COVID-19 testing.
* Families First Coronavirus Response Act (FFCRA) (PL 116-127, March 18, 2020, 134 Stat 178); Coronavirus Aid, Relief, and Economic Security Act (CARES Act) (PL 116- 136, March 27, 2020, 134 Stat 281).
From Blue Shield: (full text here)
Will Blue Shield cover costs for testing so my employees can return to work?
Blue Shield will comply with the latest DMHC emergency regulation issued on July 17, 2020 regarding COVID-19 testing for “essential workers” and other individuals until the end of the public health emergency.
More information on the DMHC regulation and testing guidance is available here. Return to work testing is not done to improve the health outcome of the employee being tested, and, therefore, would not be covered as a benefit under a Blue Shield or Blue Shield Promise health plan, except where testing is required for essential workers under the DMHC emergency regulation noted above.
For a definition of who qualifies as an essential worker, please refer to the DMHC FAQ on COVID-19 Testing. This is consistent with coverage for other types of testing that might be administered for the benefit of an employer, such as employer-required drug or alcohol testing, which is not covered as a health plan benefit.
Will Blue Shield and Blue Shield Promise cover COVID-19 screening and testing?
Yes. Blue Shield and Blue Shield Promise will waive out-of-pocket costs for co-payments, coinsurance, and deductibles for COVID-19 diagnostic testing and related screening services ordered using telemedicine and for testing and screening services ordered or performed in a doctor’s office, urgent care, hospital, or emergency room in accordance with applicable state and federal law.
Coverage is provided for diagnostic testing that is determined to be medically appropriate by an individual’s healthcare provider in accordance with current accepted standards of medical practice. This may include testing of symptomatic patients, as well as testing of asymptomatic patients when determined to be medically necessary based on an individualized assessment of the patient, such as for an upcoming procedure or recent known or suspected exposure to an infected individual.