The State of COVID-19 Testing Coverage and Accessibility

As we approach Thanksgiving, many families and loved ones are gathering together for the first time in two years, thanks in no small part to a widespread vaccination campaign. Despite this progress, vaccines have not eliminated the need for COVID-19 testing; evidence from this summer shows that fully vaccinated individuals, while significantly more protected than unvaccinated individuals, can still contract and spread the novel coronavirus. As people gather indoors over the holidays and then return to the office or classroom, affordable, rapid-turnaround testing is more important than ever.

Throughout the pandemic, CHIR has played an active role in monitoring and analyzing federal policies that have impacted accessibility of COVID-19 testing. As a part of the COVID-19 relief bills passed in the spring of 2020, health plans are required, until the end of the federal COVID-19 Public Health Emergency (PHE) to cover COVID-19 testing without imposing cost sharing on consumers. The Biden administration has interpreted this requirement to extend to tests for both symptomatic and asymptomatic individuals, although federal rules do not require plans to cover COVID tests for workplace safety or public health surveillance. (Some state laws or union contracts may require employers to pick up the costs if they mandate testing for their workers). Unfortunately, the promise of free testing is not the reality for many people, with widespread reports of providers charging up front or sending patients large and unexpected balance bills for COVID-19 testing and ancillary services.

Where are the Free Tests?

People who are uninsured or lack a primary care provider face the greatest barriers to accessible COVID-19 testing. Many mass-testing sites that were run by state and local municipalities began shutting down last summer, leaving few options for those who do not have easy access to a health care provider. In addition, health care providers are not required to provide free testing for uninsured residents. Although Congress set up the Provider Relief Fund to reimburse testing costs for the uninsured and some states have authorized their Medicaid programs to reimburse providers for testing uninsured residents, many providers find it easier to simply charge uninsured patients for their testing services.

Some major cities still provide accessible testing options for residents. For example, DC offers at-home testing where residents pick up and drop off self-administered tests at local libraries. However, the 3–5 day turnaround makes the tests of questionable utility. In New York City the free testing program provides a 24-hour turnaround guarantee, but most cities are not this efficient. Indeed, smaller towns and rural areas may rely on the local hospital or health system, but they often require payment upfront, even for insured residents. For example, Cape Cod Hospital, the largest health care system for most Cape residents, charges $110 for a PCR test if the reason is that people need to travel or “monitor their health.” Federal rules require plans to cover tests, but only if they’ve received an “individualized” determination from a health care professional that a test is needed. This, however, is a relatively low bar – the health professional does not need to be a physician and can be the person who administers the test. Insured patients could ask their plans to reimburse them for the testing costs paid upfront, but many are not aware of this option and insurers often make it administratively burdensome to apply for reimbursement.

Facility Fees, Visit Charges, and More

While health plans are required to pay for COVID-19 tests, enrollees may face additional costs related to testing. Federal guidance requires plans to cover all services that relate to a visit for a COVID-19 test in a provider office, urgent care facility or emergency room. However, coding challenges can make it difficult for an insurer to know if the primary source of the visit was a COVID-19 test. If this happens with an out-of-network provider, a patient’s out-of-pocket costs may be even higher. Hospital testing sites can also be a common source of surprise bills for COVID-19 tests. Emergency departments have been known to tack on facility fees for COVID-19 tests, even if they occur in a drive through or in a tent set up outside of the hospital.

On-demand primary care and concierge medicine providers like One Medical or Same Day Health as well as many urgent care facilities advertise easy and accessible COVID-19 tests. These accelerated services can be especially beneficial for those who have a deadline for getting test results, like a family gathering or a flight, but they come at a price. Some of these providers are offering people faster turnaround on test results if they pay an additional upfront fee—something health plans are also not required—and unlikely—to pay for. Same Day Health offers COVID-19 testing for insured residents for $75 for a guaranteed 16 hour or less turnaround time. In addition, their prices for “self-payer” range from $95 to $250 for a PCRs test with a one-hour turnaround. In New York City several clinics are charging up to $389 for two-hour turnarounds for PCR tests. But efficient testing may be inaccessible to residents who do not have the financial means to pay for a quicker turnaround.

Waiting on the Promise of Rapid and At-Home Tests

Rapid antigen tests have been touted as a great way to expand our COVID-19 testing infrastructure. While less accurate than PCR tests, they can provide results in minutes instead of hours or days, and some can be self-administered at home. Most important, they provide actionable, timely diagnoses that can help limit community spread. However, insurers do not generally cover over-the-counter tests, meaning that the consumer must pick up the full cost. At $20 per test or more, these antigen tests can quickly become cost prohibitive for anyone who needs to get tested regularly due to their employment or living situation, or for anyone who needs to get results for the whole family prior to a holiday gathering.

Where Do We Go from Here?

The federal coverage requirement for COVID-19 testing expires at the end of the PHE, currently set for mid-January. Even if the PHE is extended further, it is unlikely that the need for affordable and accessible COVID-19 testing will go away next year. While some states have codified aspects of the federal ban on cost sharing, their reach only extends to state-regulated health plans. Congress could make the testing coverage requirement permanent, or the U.S. Preventive Services Task Force could recommend COVID-19 testing as a clinically appropriate preventive service, meaning that health plans would be required to cover it and waive cost-sharing, even after the end of the PHE. In addition to a coverage mandate, federal and state governments may need to expand capacity and funding for COVID-19 testing at community health centers and other publicly supported providers serving those who lack insurance. Congress could also bolster testing availability by closing some of the loopholes that are currently leaving consumers vulnerable to surprise bills, particularly by prohibiting providers from billing patients (as is currently required for COVID vaccine administration), or from imposing facility or other fees that may accompany COVID-19 testing. Federal or state reimbursement guidelines or rate setting could also help prevent price gouging by hospitals and other providers, though this could be a significant political challenge. If Congress does not take action to lower the prices of COVID-19 tests, we will all feel the pain of price gouging when the cost filters into our health plan premiums.

As the holiday season approaches, reunions and long-awaited gatherings will come at a greater risk of unnecessary spread if obstacles to COVID-19 testing persist. When there is a financial obligation tied to testing, fewer people get tested. Additional policies are needed to close all of the gaps that leave consumers holding the bag. Without providing a path to more accessible and widespread testing, the pandemic will continue to drag on well beyond our end-of-year celebrations.

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The opinions expressed here are solely those of the individual blog post authors and do not represent the views of Georgetown University, the Center on Health Insurance Reforms, any organization that the author is affiliated with, or the opinions of any other author who publishes on this blog.