Loopholes that have led to out-of-pocket costs for COVID-19 testing

Gaps in the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act leave some patients with private insurance unprotected when they get a COVID-19 test from an out-of-network provider — those providers are not limited in what they can charge patients and are allowed to bill patients directly for the entire cost of testing and related services, leaving insured patients to submit claims for reimbursement themselves.

Federal law also does not prohibit out-of-network providers from balance billing for COVID-19 tests and related services. Instead, the law requires providers to publicly post their cash charges for testing and related services and requires insurers to reimburse the providers at their cash price if posted, but the law is silent on what insurers must pay for COVID-19 tests and related services rendered by out-of-network providers if no cash price has been posted.

Additionally, COVID-19 testing may not qualify for coverage by private insurance if it is deemed to not be medically necessary, for example, testing for travel or employment.

Patients with Medicare have more comprehensive coverage for COVID-19 testing with no cost sharing. This also is true for Medicaid enrollees while states are receiving enhanced federal matching funds tied to the COVID-19 public health emergency.

After the public health emergency is lifted, some Medicaid enrollees may face nominal cost sharing, and some Medicaid adults (low-income parents, pregnant women, seniors, and people with disabilities who do not receive an “alternative benefit plan”) may not have coverage unless states choose to cover diagnostic tests.

Lack of comprehensive protections against out-of-pocket costs for COVID-19 treatment

In contrast to COVID-19 testing, there are few federal requirements related to COVID-19 treatment. For example, no changes were made to Medicare cost sharing rules, meaning that Medicare beneficiaries in traditional Medicare could face more than $1,400 in cost sharing if they are hospitalized for COVID-19 and do not have supplemental coverage, while those in Medicare Advantage could face higher or lower costs for a hospitalization depending on their plan.