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Cost-Sharing During COVID-19

ACP Chapter Action Tool Kit

Prepared by ACP’s Division of Governmental Affairs and Public Policy

April 17, 2020

Summary

ACP is concerned that cost-sharing, which discourages medically necessary care as well as unnecessary care, and coverage gaps may pose a significant barrier to the testing and treatment of COVID-19 patients. In general, while ACP is encouraged that health insurance company representatives have announced that they will cover COVID-19 services and waive some or all cost-sharing, federal and state action is necessary to ensure these promises become reality.

On April 11, 2020, the Centers for Medicare & Medicaid Services (CMS), together with the Departments of Labor and the Treasury, issued guidance to ensure Americans with private health insurance have coverage of COVID-19 diagnostic testing and certain other related services, including antibody testing, at no cost. The guidance implements the recently enacted Families First Coronavirus Response Act (FFCRA) and Coronavirus Aid, Relief, and Economic Security (CARES) Act, which require that private health issuers and employer group health plans cover COVID-19 testing and certain related items and services furnished during the COVID-19 pandemic, with no out-of-pocket expenses. Specifically, the announcement implements the requirement for group health plans and group and individual health insurers to cover both diagnostic testing and certain related items and services provided during a medical visit with no cost sharing. This includes urgent care visits, emergency room visits, and in-person or telehealth visits to the doctor’s office that result in an order for or administration of a COVID-19 test. Covered COVID-19 tests include all FDA-authorized COVID-19 diagnostic tests, COVID-19 diagnostic tests that developers request authorization for on an emergency basis, and COVID-19 diagnostic tests developed in and authorized by states. It also ensures that COVID-19 antibody testing will be covered.

Some private insurers, such as Blue Cross Blue Shield, CIGNA, and Humana, have already announced that they are waiving cost-sharing for testing and treatment. Chapters should push other payers to do the same and/or push states to require coverage.

Action:

ACP chapters should urge insurers, state insurance commissioners and lawmakers, and other public officials to:

• Eliminate cost-sharing (co-pays, co-insurance, deductibles) for diagnostic testing (labs) and cost-sharing related to testing including hospital, emergency department, urgent care, and physician office visits. 
• Prohibit prior authorization for testing and all services related to testing. 
• Ensure coverage for testing and related services regardless of network status of the provider.  
• Ensure adoption of above policy changes to all plans including high deductible plans,  short-term limited duration insurance (STLDI)  plans, association health plans (AHPs) and Medicaid plans.  
• Require communication to all contracted providers, pharmacies and enrollees of these policy changes.  

Resources: