New federal regulations will require private insurance companies to cover at-home coronavirus testing that Americans purchase in pharmacies and other shops starting Saturday. The new system could allow millions of consumers to purchase tests at thousands of locations, without having to spend any money.
In reality, however, it is likely to be worse: Some insurance companies say it could take weeks to put together the system the White House wants.
The new process will be hard, the insurers say, because over-the-counter coronavirus tests are different from the doctor’s visits and hospital stays they typically cover.
The tests don’t currently have the billing codes that insurance companies use to process claims. Health plans rarely process retail receipts; instead they’ve built systems for digital claims with preset formats and long-established billing codes.
In this regard, some insurers have decided to handle the rapid test claims manually right from the beginning.
“This is taking things back to the olden days, where you’ll have a person throwing all these paper slips in a shoe box, and eventually stuffing it into an envelope and sending it off to a health insurer to decipher,” said Ceci Connolly, president and C.E.O. Alliance of Community Health Plans, which represents smaller, non-profit insurers.
Ms. Connolly also complained about the implementation timeline, pointing out that the government issued rules on a Monday and they will take effect on Saturday.
“It is going to be exceedingly difficult for most health plans to implement this in four days,” she said.
The challenges of insurers may soon trickle down to consumers, who will be responsible at first for navigating their health plans’ reimbursement rules to get their tests covered.
“There will be some people who buy them, and then have a six-month nightmare trying to get reimbursed,” said Jenny Chumbley Hogue, a Texas-based insurance broker. She has yet to see a plan she has worked with that has sent member guidance about how coverage will be handled.
Ms. Hogue isn’t sure what the rules will be so she advises her clients to save their receipts and the boxes in which the tests are sent. Some plans may require the boxes to prove purchase.
The White House gave a statement to The New York Times on Friday encouraging patients to hold on to receipts for the tests they purchase: “If Americans are charged upfront, it is important that they keep their receipts and be prepared to submit them for reimbursement. The most important thing is that starting Saturday those tests are covered free of charge.”
Some public health experts have criticised the plan as too complicated and suggested that they would prefer for the Biden administration directly to provide free kits to patients.
“The direct provision of inexpensive tests for the American public would be the simplest from a consumer standpoint,” Lindsey Dawson, an associate director at the Kaiser Family Foundation, previously told The Times. “Someone will need to know it’s reimbursable, navigate the reimbursement process, and front the cost to begin with.”
Other countries have invested more in rapid testing. Citizens in Britain can order free rapid tests from a government website. Germany spent hundreds of million of dollars to establish a network with 15,000 rapid testing centers. Instead, the United States has shifted its public purchasing to vaccines and encouraged their uptake.
In an effort to combat the current wave of cases, some US local governments have invested heavily in rapid tests. Washington, which has seen a significant rise in virus cases, allows residents to now receive four free rapid testing at their local libraries each day.
The Biden administration has instead relied more heavily on tests delivered in doctor’s offices. Since the outbreak, federal laws have required that insurance companies cover the tests at no cost.
The new rules require private insurance companies to cover eight home coronavirus testing for each person each month. The rules will not apply retroactively if Americans have already purchased at-home coronavirus tests. They also don’t cover patients who have public insurance like Medicare and Medicaid.
Under the new rules, consumers who get tests at their health plan’s “preferred” location will have the costs covered upfront, meaning the patient will pay nothing out of pocket. What counts as a “preferred” location will vary from one plan to another, although many expect those facilities to be ones that are already in-network with a given insurer.
Consumers who visit an out-of network store will need to provide receipts for reimbursement. The plan will only have $12 per test or $24 for a set with two tests. Patients who pay more than the sticker price will be responsible.
Health plans that do not designate a set of “preferred” locations will have to cover the full costs of test receipts that their members submit.
According to Ms. Dawson’s research last week, test prices range from $17.98 per pack of two to $49.99 per individual test.
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Highmark Health, a nonprofit plan in Pennsylvania with around six million members, plans to create a network of “preferred” locations but will not have it ready by this Saturday.
“The guidance came out Monday, and we started working on it immediately, but I don’t have a mechanism ready to go, Day 1, where you don’t have to pay upfront,” said Bob Wanovich, a Highmark vice president who works on provider contracting.
One of the challenges Mr. Wanovich, along with others, described was that insurance companies don’t typically cover over-the–counter items at the pharmacies like a pregnancy check or nonprescription medications.
“Retailers need to have a process to capture the right codes, and submit it, and we need to be able to accept it on our end,” he said. “These are the pieces that aren’t there yet.”
Until they set up that infrastructure — a process that could take weeks — Highmark Health will be advising patients to submit receipts along with a photograph of their test kit’s bar code for reimbursement.
Capital District Physicians’ Health Plan, a small insurer in upstate New York, plans to instruct members to hold on to their test receipts as it sorts out a system for processing them.
“We’re getting a ton of calls from consumers asking about it, so we’re trying to arm our member service staff with the right information,” said Ali Skinner, the plan’s vice president for communications.
Ms. Skinner said the insurer was still working to have “preferred” locations designated by Saturday, so patients could pick up tests without the reimbursement process, but She was unsure whether the deadline would be met.
“We’re up against the clock right now,” she said. “It’s a big lift for us. We found out at the same time as consumers did on Monday.”
Even though insurers are working to improve their claims processing systems, they pointed out that one factor is out of their control: the testing of supply and the shortages consumers have faced in recent weeks.
“The bigger frustration our members have is over finding a test, and I don’t have any control over the supply,” said Mr. Wanovich of Highmark Health. “We’re working with our providers to figure out who has them, but we know it’s in short supply.”
Source: NY Times