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-19 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.
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-19 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-19 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.
