Pence says HHS has designated coronavirus testing as an “essential health benefit,” which means the test will be covered by health insurance plans, Medicare and Medicaid.
— Franco Ordoñez (@FrancoOrdonez) March 4, 2020
I don’t know what this means.
The ACA requires plans that are regulated by the ACA and some Medicaid plans to offer 10 Essential Health Benefits. These are fairly broad categories of services including inpatient hospitalization, rehab, prescription drugs and for COVID-19 purposes, lab and diagnostic services. If there is a COVID-19 test or subsequent treatment of an individual who tests positive, their testing and treatment is already covered as an EHB. An EHB is a fairly broad category and it is not a government list of codes or procedures.
However there is a difference between an allowable benefit and a no cost sharing benefit. Right now, most EHBs can and will have significant cost sharing attached to it. Using the 2020 Healthcare.gov Benefits and Cost Sharing public use file, 78% of ACA on-exchange plans charge at least deductible to the use of a lab. Roughly 93% of plans offered on Healthcare.gov for 2020 have some cost-sharing with some combination of deductible, co-pay or co-insurance.
Making COVID-19 testing an EHB does nothing different.
Now if the intent is to make COVID-19 testing a no-cost sharing service, then there is a pathway through the EHB logic but it is not simple. One of the EHBs is for preventive services and screenings. These services are no cost sharing. Preventive services include vaccines, a lot of developmental screenings for kids, colon cancer checks and now PrEP for individuals at high risk of being infected by HIV. This is a plausible pathway.
However current regulations requires the US Preventive Services Task Force to give a service an A or B rating. Furthermore, there is black letter law in the ACA that requires a one year warning period before a new service recommendation becomes zero cost sharing:
The bigger problem is that the ACA imposes a statutory one-year waiting period before new preventive tests can be mandated without cost-sharing.
— Nicholas Bagley (@nicholas_bagley) March 4, 2020
Now if the intent is to get COVID-19 testing to be no cost sharing and thus remove a financial barrier, this is a good goal. But the Administration needs Congress here. Congress could pass a 2 page bill that says that in the case of a declared public health emergency of new/emerging infectious diseases, these requirements can be waived for 180 days as long as the Secretary of HHS or the Surgeon General or some other executive branch official reports to Congress why the waiver is needed.
UPDATE 1: This New York State insurance circular letter is instructive on EHBs:
It is important to remove barriers to testing for COVID-19. Currently, COVID-19 tests are being conducted at New York State’s Wadsworth Center and are fully covered. However, it is anticipated that additional labs will be approved for testing. Issuers are reminded that laboratory tests are an essential health benefit (“EHB”), and as such, must be covered under individual and small group comprehensive health insurance policies and contracts….
The question is not if a COVID-19 screen is a covered benefit under current EHB regulation. The question is who pays and if there are barriers to access and care.
Cheryl Rofer
Thanks, Dave. I’ve been wondering about this.
Sab
Thank you for screening the b.s. That should be the governments job, but they aren’t doing it.
As a responsible citizen, if I have symptoms of corona I should be tested and screened. As a responsible member of my nuclear family, I know that the government doesn’t know what it is doing and nobody will pay for anything so I should just hunker down and self quarantine.
Why in phuck would I submit to testing that could subject my family to thousands of dollars of test costs, mandatory hospital quarantines that would increase exposure, if we could just hunker down at home.
Dupe1970
Any competent administration would have already requested this power. Even Dubya would have given a speech filled with homilies while asking Congress for this.
PenAndKey
@Sab: This is, sadly, where a lot of us stand on the issue. Even if the testing is covered why on earth would the people least able to afford the ensuing medical bills and hospital or employer mandated quarantines, also known as most employees, voluntarily seek out testing? Few people are so community minded they will volunteer to risk homelessness by losing that large a chunk of employment and pay, after all.
Zzyzx
My office is voluntarily closed for at least 2 weeks. That’s fine for us but what happens to the restaurants in the lobby?
Frankensteinbeck
@Dupe1970:
Yep. New Orleans would have been handled with minimal competence if it wasn’t seen as black. Coronavirus does not have that stereotype. Dubya would have done a bad job of handling this, but he would have tried.
trnc
And, if I understand correctly, black letter law still applies to anything associated with Obama and not related to dem congressional oversight.
OzarkHillbilly
I think you answer your question here:
And when it doesn’t happen they get to blame Obama and the ACA without having to do all that nasty legislating work! See? Win win!
Sloane Ranger
So, stuff is getting real for me here in rural Northamptonshire. Our 1st case of Corona virus has been diagnosed. Apparently picked up in Northern Italy rather than home grown but, even so.
My AmDram group has just finished casting for our summer production and we had 2 cast members this morning announcing that they would be self isolating for prevention purposes if local infection is ever confirmed as they have compromised immune systems.
Small consolation is that our Conservatives still have some relationship with reality. They are changing the law to allow people to claim statutory sick pay from Day 1 if they are advised to self isolate, rather than Day 4 as currently. Also paying for a massive public information campaign about importance of washing your hands. They have also publicised their contingency plan for if things go really south.
Sab
@Sloane Ranger: Wish you well from Ohio ( Ohoho).
Brachiator
Pence, like his boss, apparently believes that there are no laws, only the declarations of or Emperor King Trump.
Great point. Of course, the issue is magnified for any who end up testing positive.
PenAndKey
And, because this is Murca!™ the news will make a few token articles about how hard it is for everyone but ultimately nothing will be done to address the elephant in the room. When it comes to healthcare and actual healthcare consequences the working classes never get more more than token platitudes in this country.
But, like Ozark said in #8, the law is pretty clear this that is a dead issue and that Pence doesn’t have the authority under the law to do what he wants here so nothing will happen. They’ll all just conveniently ignore that the federal government has the legal authority to nationalize the response and they’re only required to offer a “reasonable” compensation to any test kit or treatment producer, should they choose to.
Victor Matheson
ACA policy nerd here. Great post.
Almost certainly it was never in doubt that this sort of diagnostic testing would be an essential health benefit. This sort of test, if a doctor suggests that it would be reasonable, is covered both under:
3. Preventive and Wellness Services and Chronic Disease Management (which includes things like screenings, doctors visits, and vaccines) as well as
9. Laboratory Services (which includes tests to diagnose for disease as well as preventive screening).
But yeah, everything in the ACA, including all essential health benefits are subject to cost sharing, with only rare exceptions.
JaySinWA
Just got an email from CMS indicating coverage under Medicare Part B and stating that such coverage is normally free. FWIW.
They link to the web page here: https://www.medicare.gov/coverage/coronavirus-test
lurker3000
And they just passed a funding bill extremely fast. Why not put something like that in the funding bill?
JaySinWA
From the Seattle TImes;
No deductibles, co-pays for coronavirus visits, tests
Washington state’s insurance commissioner issued an emergency order Thursday directing all health insurance carriers, through May 4, to provide health care provider visits and novel coronavirus testing without co-payments and deductible payments to enrollees who meet criteria for testing.
Questions about coronavirus testing and treatment costs have stirred some concern about people without insurance, as well as insured people without savings. People anxious about costs may delay care and thereby contribute to the spread of the virus, public health experts have said.
—Daniel Beekman and Joseph O’Sullivan