Why Rapid Covid Tests May Not Be Free Upfront at First

Starting Saturday, new federal rules will require private insurers to cover at-home coronavirus tests Americans buy at drugstores and other stores. The new system could, in theory, allow millions of consumers to take tests at thousands of sites without spending any money.

The reality, at least in the short term, is likely to be more chaotic: Some insurers say it will likely take weeks to fully prepare the system envisioned by the White House.

Insurers say the new process will be challenging, because over-the-counter coronavirus tests are different from the doctor visits and hospital stays they usually cover.

Tests do not currently contain the type of billing codes that insurance companies use to process claims. Health plans rarely process retail receipts; Instead, they built digital claims systems with predefined formats and legacy billing codes.

For this reason, some insurance companies plan to administer express test claims manually initially.

“It takes things back to the good old days, where you would have someone throw all these paper scraps into a shoebox, and eventually stuff them in an envelope and send them to a health insurance company for decoding,” said Ceci Connolly, president and CEO of the Community Health Plans Alliance. , which represents not-for-profit micro-insurance companies.

Ms Connolly also criticized the implementation timetable as being too hasty, with the government issuing rules on Monday that are set to go into effect on Saturday.

“It would be very difficult for most health plans to implement this in four days,” she said.

Insurers’ challenges may soon pass to consumers, who will initially be responsible for navigating their health plans’ reimbursement rules to cover their tests.

“There’s going to be some people who buy them, and then they’re going to have a six-month nightmare trying to get compensation,” said Jenny Chumbly Hogg, a Texas insurance broker. She has yet to see a plan to work with and has sent out directions to members on how to handle coverage.

Unsure of what the rules are, Ms. Hogg advises her clients to save not only receipts but also the boxes that tests come in, as some plans may require boxes as proof of purchase.

Some public health experts have criticized the plan as unnecessarily complex, saying they would have preferred the Biden administration to provide free kits directly to patients.

“Direct provision of inexpensive tests to the American public would be simpler from a consumer point of view,” Lindsey Dawson, associate director at the Kaiser Family Foundation, previously told The New York Times. “Someone will need to know it’s repayable, navigate the reimbursement process, and the cost initially.”

Other countries have spent more money on rapid tests. In Britain, citizens can use a government website to order free express tests for home use. Germany has invested hundreds of millions of dollars to create a network of 15,000 rapid test sites. Instead, the United States has focused public procurement on vaccines, and efforts to encourage uptake.

Some local governments in the United States have invested heavily in rapid testing to cope with the latest wave of cases. Washington, which has seen a spike in virus cases, is now allowing residents to run four free rapid tests per day at libraries across the city.

Instead, the Biden administration has relied more on tests performed in doctors’ offices. Federal laws require insurance companies to cover those costs at no cost to the patient from the early months of the pandemic.

The new rules require private insurers to cover eight home coronavirus tests per person, each month. The rules won’t apply retroactively to at-home tests Americans have already bought, and they don’t cover patients with public insurance like Medicare and Medicaid.

Under the new rules, consumers who undergo tests at their health plan’s “preferred” location will have costs covered up front, meaning the patient will have nothing to pay out of pocket. What counts as a “preferred” location varies from plan to plan, although many would expect those facilities to already be in the network with a particular insurance company.

Consumers who go to an out-of-network store will need to submit receipts for compensation, and the plan will only have to pay $12 per test (or $24 for a set with two tests). If the sticker price is higher, the patient will be responsible for the additional fee.

Health plans that do not specify a set of “preferred” sites will have to cover the full costs of test receipts sent by their members.

Test prices currently range from $17.98 for a pack of two to $49.99 for a single test, according to research by Ms. Dawson last week.

Highmark Health, a Pennsylvania nonprofit with about six million members, plans to build a network of “favorite” sites but it won’t be ready by Saturday.

said Bob Wanovich, a senior vice president of Highmark who is working on contracting with the provider.

One of the challenges described by Mr. Wanovitch and others was that insurance companies do not usually cover over-the-counter things at the pharmacy, such as a pregnancy test or over-the-counter medications.

“Retailers need a process to capture and send the right tokens, and we need to be able to accept them on our end,” he said. “These are the pieces that haven’t been found yet.”

Until that infrastructure is in place — a process that can take weeks — Highmark Health will advise patients to submit receipts with an image of their test kit barcode for compensation.

The Metropolitan Area Physicians Health Plan, a small insurance company in upstate New York, plans to instruct members to keep their test receipts as it sorts out a system to process them.

“We get a huge number of calls from consumers asking about it, so we try to provide member service personnel with the right information,” said Ali Skinner, the plan’s vice president of communications.

Ms Skinner said the insurer was still working to assign “preferred” sites by Saturday, so patients could take tests without the reimbursement process, but She was unsure if she would meet the deadline.

“We are against the clock now,” she said. “It’s a huge lift for us. We discovered it at the same time as consumers did on Monday.”

Even as insurers sort through their claims processing systems, they note that one major factor will remain outside their control: supply testing, and the shortages consumers have faced in recent weeks.

“The biggest frustration for our members is finding a test, and I have no control over the offer,” said Mr. Wanovich of Highmark Health. “We are working with our suppliers to find out who owns them, but we know they are in short supply.”

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