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New Guidance: Coverage of COVID-19 Diagnostic Testing and Vaccines

Last week the Biden administration issued guidance (FAQ 44) removing barriers to COVID-19 diagnostic testing and vaccinations and strengthening requirements that plans and issuers cover diagnostic testing without cost sharing during the emergency period. Through previous guidance and rulemaking (see our November 2020 update), the agencies have addressed coverage requirements for COVID-19 vaccines and diagnostic testing. This most recent guidance further expands upon and clarifies these policies.

Diagnostic Testing The latest guidance clarifies that private group health plans, including grandfathered health plans, 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. Such testing must be covered without cost sharing, prior authorization, or other medical management requirements to include tests for asymptomatic individuals without known or suspected exposure to COVID-19.

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. So plans must provide coverage for items and services furnished to an individual during health care provider office visits (including in-person visits and telehealth visits), urgent care center visits, and emergency room visits that result in an order for or administration of an in vitro diagnostic product, but only to the extent that the items and services relate to the furnishing or administration of the product or to the evaluation of the individual for purposes of determining the need of the individual for that product. 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.

While plans must provide coverage without imposing any cost-sharing requirements for COVID-19 diagnostic testing of asymptomatic individuals when the purpose of the testing is for individualized diagnosis or treatment of COVID-19, the guidance is clear that plans are not required to provide coverage of testing such as for public health surveillance or employment purposes. However, the guidance also notes that there is no prohibition or limitation on plans providing coverage for such tests. Plans should ensure that communications about the circumstances in which testing is covered are clear.

Vaccine Administration

This guidance also reinforces the existing requirement for non-grandfathered plans to cover, without cost sharing, qualifying coronavirus preventive services, including recommended COVID-19 vaccines. The Centers for Disease Control and Prevention (CDC) also makes available a wealth of information about the COVID-19 vaccine on its COVID-19 website.

One FAQ clarifies that the federal government is providing the vaccine free of charge to all people living in the United States, and that vaccination providers can be reimbursed for vaccine administration fees by the patient’s public or private insurance company. We refer you to these CDC resources as they may be useful for communicating with plan enrollees. Specifically, the website provides access to information about who gets vaccinated first, what to expect at the vaccine appointment, benefits of getting vaccinated, the safety of vaccines, and more.

Please contact your Conner Strong & Buckelew account representative toll-free at 1-877-861-3220 with any questions. For a complete list of Legislative Updates issued by Conner Strong & Buckelew, visit our online Resource Center.


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