COVID-19 No Cost Sharing Mandate - Permissible to Exclude Due to Lack of Medical Necessity?

[rocknrolls2]

Because there is a higher incidence of COVID-19 positive test results for residents of a long-term care facility (i.e., a nursing home), State X mandates that all residents and staff at the facility be tested for COVID-19 by a specified date. Those individuals who test negative are required to be retested within one week to rule out a false negative on the first test. There will only be a second retest if and to the extent that the Centers for Disease Control and Prevention mandate it. My question is, in light of the no cost-sharing of COVID-19 testing imposed by the Families First Coronavirus Response Act, as applied to a self-funded plan, does this mean that the plan (or employer) is saddled with the cost of conducting the testing? Can the plan deny coverage for the retest as not medically necessary?

[Scooter]

See page 3 of 4 for Items and services furnished to an individual during health care provider office visits, then the example on the right side top of how plans must cover other tests as part of the evaluation of an individual for COVID-19.  In the Example: ...... 'and the visit results in an order for or administration of, COVID-19 diagnostic testing, the plan or issuer must provide coverage without cost sharing, when medically appropriate for the individual, as ddetermined by the individual's attending healthcare provider in accordance with acceptable standards of current medical practice.

 

FAQs on COVID-19 and Health Coverage -KEYSTONE 041720 by ER.PDF

[leevena]

14 minutes ago, Scooter said:

See page 3 of 4 for Items and services furnished to an individual during health care provider office visits, then the example on the right side top of how plans must cover other tests as part of the evaluation of an individual for COVID-19.  In the Example: ...... 'and the visit results in an order for or administration of, COVID-19 diagnostic testing, the plan or issuer must provide coverage without cost sharing, when medically appropriate for the individual, as ddetermined by the individual's attending healthcare provider in accordance with acceptable standards of current medical practice.

 

FAQs on COVID-19 and Health Coverage -KEYSTONE 041720 by ER.PDF 596.73 kB · 1 download

Scooter.  Do you know what happens to the waived amounts?  Does the carrier need to pay the provider the waived copay, or does the provider eat it?  Thanks

[Scooter]

Due to the plan or issuer must provide coverage without cost sharing, when medically appropriate for the individual, the Plan or Issuer would pay the provider of service / test determined by the individual's attending healthcare provider as the agree network fee or in non-network provider disclosed price at time of service or posted on their provider website, which can be confirmed or negotiated by the Plan / Issuer if neither apply.

[leevena]

3 hours ago, Scooter said:

Due to the plan or issuer must provide coverage without cost sharing, when medically appropriate for the individual, the Plan or Issuer would pay the provider of service / test determined by the individual's attending healthcare provider as the agree network fee or in non-network provider disclosed price at time of service or posted on their provider website, which can be confirmed or negotiated by the Plan / Issuer if neither apply.

Thank you.  So if I understand correctly, if the copay is waived, it is actually the provider who is giving up revenue, not the plan.