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COVID-19 Testing Insurance Coverage

Should I Get a COVID-19 Diagnostic Test?

Before getting tested, you should ask the following questions:

Know Your Coverage

Before you get tested for COVID-19, you need to understand what kind of health care coverage you have. The laws and regulations that govern health care coverage can impact different types of coverage in different ways.

If you have symptoms or a known or suspected recent exposure and have health care coverage through a government program:

  • Medicare and Medicare Advantage

    Testing: Medicare covers the lab tests for COVID-19 with no out-of-pocket costs and the deductible does not apply when the test is ordered by your doctor or other health care provider. 
  • Medical Assistance (MA) and CHIP

Testing: For Medical Assistance (MA) and CHIP, all lab tests, including tests for COVID-19, are covered without copayments or prior authorization.
If you want to be tested for COVID 19 without symptoms and have health care coverage through a government program:

  • Medicare and Medicare Advantage

If the test is recommended by an attending healthcare provider, the Families First Coronavirus Response Act requires coverage for the order of and administration of the test with no cost-sharing and no prior authorization. If you are without symptoms (or asymptomatic), testing is covered for residents and patients of nursing homes.

  • Medical Assistance and CHIP

If the test is recommended by an attending healthcare provider and the provider writes an order for the test, the Families First Coronavirus Response Act requires coverage for the order of and administration of the test with no cost-sharing and no prior authorization.
 
If you have symptoms or a known or expected exposure and have health care coverage directly from an insurance company, the federal health insurance marketplace, or through your employer (including through COBRA):

  • A test must be covered if your attending healthcare provider has assessed your individual situation and determined that it is medically appropriate, i.e., that you have symptoms or have a known or likely recent exposure to COVID-19.
    • Contact your insurance company to make sure your lab is in-network or check to see what provisions the insurer has put in place for out-of-network lab work. Hospitals and providers are expected to bill insurance companies for the fees associated with collecting the specimens, and labs are expected to bill insurance companies for the actual testing.
    • If the test is recommended by your doctor or other health care provider, the Families First Coronavirus Response Act and CARES Act require coverage for the order for and administration of the test with no cost-sharing and no prior authorization or other medical management requirements for provider visits (office, urgent care, Emergency Room) that result in an order for or administration of a COVID-19 test.

If you want to be tested for COVID-19 without symptoms or known or suspected recent exposure and have health care coverage directly from an insurance company, the federal health insurance marketplace, or through your employer (including through COBRA):

  • Check with your insurance company.  Often, a patient authorization phone number is listed on the back of your health insurance card. The Families First Coronavirus Response Act and CARES Act do not require an insurance company to pay for a test unless you have symptoms or a known or recent exposure to COVID-19 and it has been determined to be medically necessary for you by an attending healthcare provider.

If you want to be tested for COVID 19 with symptoms and have health care coverage through the Pennsylvania Employee Benefit Trust Fund (PEBTF):

  • Testing:  PEBTF/Retired Employees Health Program (REHP) medical plans will waive all deductibles, coinsurance and copays for diagnostic testing and in-network inpatient hospital care, emergency room or urgent care for COVID-19. The policy will cover the test kit for members who meet Centers for Disease Control and Prevention (CDC) guidelines for testing in any approved laboratory location. 

If you want to be tested for COVID-19 without symptoms and have health care coverage through PEBTF:

Tests must be covered when there has been known or recent exposure to COVID-19 and it has been determined to be medically necessary by an attending healthcare provider.

* Who is considered an "attending healthcare provider"?

A health care provider is an "attending healthcare provider" if they are licensed or otherwise authorized under applicable law, acting within the scope of the provider's license or authorization, and responsible for providing care to the patient. An attending healthcare provider does not have to be directly responsible for providing care to a patient to be considered an attending provider but must be a provider who makes an individualized clinical assessment to determine whether the test is medically appropriate. Your primary care physician, a provider (i.e. a nurse, physician's assistant, doctor) at a drive through testing site, or a pharmacist are examples of people who may be considered an attending provider if they make an individualized clinical assessment that the test is medically appropriate for you.

View more information about coverage for testing.

Most people get health care coverage in one of these ways. If you do not believe you fit into any of these categories or are not sure which category you fall in, call the Pennsylvania Insurance Department at 1-877-881-6388 and we can help you figure out which type of health care coverage you have.

What should I do if my insurance won't cover COVID-19 testing or treatment?

If you have an excepted benefit policy, short-term, limited duration health insurance coverage, or a health care sharing ministry plan, you are considered "uninsured," and the Families First Coronavirus Response Act may provide options to cover your COVID-19 testing.  

However, if you believe your insurance company should be covering COVID-19 testing or treatment but is not, you need to determine what kind of health care coverage you have and contact the appropriate agency.

If you have individual, small group employer, or large group employer coverage:

The Pennsylvania Insurance Department
Web: www.insurance.pa.gov
Phone: 1-877-881-6388 or 717-783-3898

If you have employer self-funded coverage

The United States Department of Labor
Web:  https://www.dol.gov/agencies/ebsa
Phone: 1-866-275-7922

Does your employer self-fund the healthcare coverage it provides? 

Sometimes employers purchase coverage from a health insurance company for a set premium and the health insurance company pays all of the claims for health care services. This is called being fully insured. However, in many other cases, your employer will pay claims for health care services themselves and use a third party, like a health insurance company, to administer their health care coverage. This is referred to as being self-funded (or self-insured). If you are not sure if your employer self-funds or is fully insured, contact your human resources department, benefits manager, or the person in management that handles health care coverage and they can tell you.

If you have Medicare coverage:

Medicare
Web:  www.medicare.gov 
Phone: 1-800-MEDICARE

If you have Pennsylvania Medical Assistance (Medicaid):

The Pennsylvania Department of Human Services
Web: http://www.healthchoices.pa.gov
Phone: 1-866-550-4355

If you have Children's Health Insurance Program (CHIP) coverage:
Pennsylvania's Children's Health Insurance Program
Web: www.chipcoverspakids.com
Phone: 1-800-986-KIDS (5437)

What should I do if I don't have health insurance?

Whether you are experiencing symptoms or not, now is a good time to see if you are eligible for enrollment in health care coverage. Some health programs, like Medical Assistance (MA) and CHIP, will enroll you at any time throughout the year. Some health insurance coverage, like the Marketplace, may only be available if there is a Special Enrollment Period or during the annual Open Enrollment Period.  You may qualify for a Special Enrollment Period if you've had certain life events, including losing health coverage, moving, getting married, having a baby, or adopting a child.

The Pennsylvania Association of Community Health Centers (PACHC) offers free, personal, no pressure, no obligation, non-biased enrollment assistance. PACHC and its network of Community Health Centers are available to assist you in navigating and enrolling in the Health Insurance Marketplace, Medical Assistance (MA), Medicare and CHIP. Certified Exchange Assisters are available throughout Pennsylvania to help you enroll in these programs.  

Here is a list of exchange assisters in your area.  You may also search by using the find a health center page.  If you have additional questions or need further assistance, please contact the PACHC's Navigator Hub at 1-866-944-CARE (2273).

You may also use COMPASS to sign up for Medical Assistance.  COMPASS is an online tool for Pennsylvanians to apply for many health and human service programs like Medicaid and CHIP.  Visit COMPASS at www.compass.state.pa.us.   

If you would prefer to research signing up for a Marketplace plan without assistance, you may visit www.healthcare.gov.

If you are uninsured, the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security (CARES) Act may provide reimbursement to health care providers and facilities for your COVID-19 testing and treatment.

I am sick and I do not have insurance, what should I do? 

There are a variety of free and/or low-cost health care resources available to people who are uninsured, underinsured, or economically disadvantaged. The federal and non-profit organizations listed below may provide or help cover a range of medical, dental, pharmacy, vision and/or behavioral health services.

Free Clinic Association of Pennsylvania

Free & Charitable Clinics are safety-net health care organizations that utilize a volunteer/staff model to provide a range of health services. Visit Free Clinic Association of Pennsylvania to find free or charitable health clinics in your area.

Federally Qualified Health Centers

Federally Qualified Health Centers are in most cities and many rural areas. These health centers provide comprehensive primary and preventive care for all ages, regardless of your ability to pay or health insurance status.  Many health centers have COVID-19 tests available. Fees for services are on a sliding scale based on your income. Find a Federally Qualified Health Center in Pennsylvania near you.

If you are uninsured, the Families First Coronavirus Response Act and the Coronavirus Aid, Relief and Economic Security (CARES) Act may provide reimbursement to health care providers and facilities for your COVID-19 testing and treatment.

I'm an immigrant. Is there anything else I should be thinking about? 

What is the Public Charge Rule?

The new Public Charge Rule is a federal rule that came into effect on February  24, 2020. A "public charge" is someone who needs to rely on public assistance; the rule was established to ensure that individuals can sustain themselves and not burden society.  (There are lawsuits going on about this rule; please check with your legal services provider if you have any questions.)  If an individual wants to immigrate to the United States or adjust their lawful permanent residence (obtain a Green Card), the person must demonstrate that they will not be a public charge.  Under the new public charge rule, the federal government looks at certain benefits to decide if someone is a public charge, such as needing Medicaid (but not emergency services, children under 21 years, pregnant women and new mothers), Supplemental Nutrition Assistance Program (SNAP, EBT, Food Stamps), Federal Public Housing and Section 8 assistance, and cash assistance programs (like SSI, TANF, General Assistance). Please check with your legal services provider if you have any questions.  You can also learn more at uscis.gov.

Can I get tested for COVID-19 despite the Public Charge Rule? 

Yes, the U.S. Citizenship and Immigration Services encourages all those, including undocumented individuals, with symptoms that resemble COVID-19 (fever, cough, shortness of breath) to seek necessary medical treatment and preventive services.  Immigration officials have stated that testing, treatment, and preventive care related to COVID-19 will not negatively affect an individual's public charge analysis.  To learn more visit uscis.gov.

I am a health care provider, is there a place to learn more about National Immigration Laws?

If you are a health care provider, use this guide from the National Immigration Law Center to learn more about the rights of health care providers and their patients.

What arrangements can be made for the cost of the test for staff?

The Pennsylvania Department of Health encourages each facility's staff to consult with their employer to determine how the test should be paid and whether there are any particular testing arrangements in place for that facility's staff.

If there are staff without medical insurance, is there any payment mechanism for the test?

The Health Resources and Services Administration (HRSA) will cover the cost for testing for uninsured generally at Medicare rates. Information is available at https://www.hrsa.gov/coviduninsuredclaim/frequently-asked-questions.

What if I travel out of state? Why is quarantine being recommended?

Quarantine helps prevent the spread of disease that can occur before a person knows they are sick or if they are infected with the virus without feeling sick or exhibiting symptoms.  Learn more about quarantine recommendations.


Date created: 9/18/2020