united-states california health covid-19 health-insurance
Must all COVID-19 tests be fully reimbursed by health insurances in California, United States?
<p>I read on one of the COVID-19 testing websites (<a href="https://www.sccgov.org/sites/covid19/Pages/covid19-testing.aspx" rel="nofollow noreferrer">https://www.sccgov.org/sites/covid19/Pages/covid19-testing.aspx</a> but the following text can only be viewed but booking an appointment) [emphasis is mine]:</p>
<blockquote>
<p>Free testing is available to all County residents, regardless of insurance status.
If you have health insurance, <strong>your health plan is required to pay for approved COVID-19 tests</strong>, according to the State of California. By providing your insurance information, this allows the County to be reimbursed for the cost of the tests from your insurance company. <strong>Insurance companies cannot bill individuals or charge any co-payments for COVID-19 tests</strong>. Your test is no cost or “free” for you.</p>
</blockquote>
<p>This causes me: the first bold section seems to say that only <em>approved</em> COVID-19 tests must be fully reimbursed, whereas the second bold section bold says that <em>all</em> COVID-19 tests must be fully reimbursed.</p>
<p>Must all COVID-19 tests be fully reimbursed by health insurances in California, United States?</p>

<p>There are two government level directives that bear on this. <a href="http://www.insurance.ca.gov/0250-insurers/0300-insurers/0200-bulletins/bulletin-notices-commiss-opinion/upload/COVID-19-Screening-and-Testing.pdf" rel="nofollow noreferrer">This letter</a> from the insurance commissioner to all health insurers (and <a href="https://www.dmhc.ca.gov/Portals/0/Docs/OPL/APL-COVID-19WaiverOfCostShare3-5-20Final.pdf" rel="nofollow noreferrer">this functionally identical letter</a> from the acting general counsel of the Dept. of Managed Care)
directs the companies to do 5 things, the most relevant is reducing &quot;cost-sharing&quot; to zero for &quot;for all medically necessary screening and testing for COVID-19&quot; (plus, advertise this fact and make sure phone staff know this). The directive does not alter the standard for what is &quot;medically necessary&quot; – the use of &quot;approved&quot; in the website that you mentioned does not refer to anything like &quot;FDA approved&quot;, it means simply &quot;medically necessary&quot;, however the provider determines that. The relationship between the insurer and the provider is governed by separate contracts and regulations, i.e. there is no change there. Healthcare providers were not given free rein to milk insurance companies.</p>
<p>It is also true that some insurance providers add details, e.g. <a href="https://www.blueshieldca.com/bsca/bsc/wcm/connect/sites/Sites_Content_EN/coronavirus/coverage-testing" rel="nofollow noreferrer">Blue Cross</a> saying that it must be &quot;ordered by a healthcare provider licensed to order COVID-19 tests&quot;, &quot;FDA-approved, emergency use authorized, or authorized under other guidance from the Secretary of the Department of Health and Human Services consistent with the federal CARES Act&quot;, and &quot;processed in accordance with FDA and other applicable guidance&quot;, and they also clarify that
&quot;If the test is for an essential worker without symptoms or known or suspected exposure, out-of-pocket costs will apply based on the member’s benefit plan&quot;. The scope of the insurance directive is limited: it does not change anything other than patient cost-sharing in a specified context (&quot;medically necessary&quot;).</p>

<blockquote>
<p>Must all COVID-19 tests be fully reimbursed by health insurances in California, United States?</p>
</blockquote>
<p>That is not what the excerpt conveys. The second statement in bold only reflects that the insurer is not allowed to shift to the insured --or policy holder-- the cost of the test, but that is in the context of (i.e., same paragraph about) tests for which an appointment is booked with the state/county.</p>
<p>It would be improper for the state to inform about the no-cost protection only to the insured people who happen to book an appointment, since that tends to exclude every insured who did not engage in the state/county program (whether because the insured got tested outside that program and/or did not want to risk being billed by the insurer).</p>
<p>It is also unclear from the excerpt what &quot;<em>approved</em>&quot; means. For instance, approval might depend on validation that the person is truly a resident of that county. Testing a non-resident might forfeit the state's/county's right to reimbursement from the insurer for that specific test. Another possibility is that approval depends also on test's compliance with a set of specs (such as the number of amplifications of the person's sample).</p>
