coronavirus test

COVID-19 Testing – When is it covered?

submitted by Caroline McDonough, Esq.

The recent return to school for many as well as the continued return to the workplace is bringing about questions relating to the availability of coronavirus testing. While testing continues to increase across New York State, health insurance coverage for tests only remains available for medical purposes.

Federal guidance requires coverage of testing in order to diagnose coronavirus, but the guidance indicates coverage is to be made available when medically appropriate. Thus, most health insurance organizations are limiting coverage to those situations deemed medically appropriate by health care providers. Despite concerns about the potential uptick in the spread of coronavirus because of increased contact among students, teachers, and employees of large workplaces, coverage of testing is not required for people solely because of their having returned to school or work. Therefore, if testing is implemented as part of return to school or return to work policies, the responsibility should lie with the school district or the employer to pay for the cost of testing assuming one’s health insurance does not. However, people who are required to undergo testing for school or work purposes, should inquire with the district or employer to make certain he or she is not responsible for the cost of testing.

Determinations as to when a coronavirus test is medically appropriate lie with the health care providers. The New York State Department of Health issued guidance with factors to assess when ordering a test. Such factors include whether an individual is symptomatic, resides in a congregate care setting, requires medical care such as an elective surgery – just to name a few. The guidance with each of the factors to be considered and the way in which they are prioritized are available on the Department of Health’s website or by clicking here.

Currently, in Western New York, major health insurance providers such as Blue Cross Blue Shield of Western New York, Independent Health Association, and Univera Healthcare are rendering coverage of coronavirus tests in accordance with the federal guidance. Therefore, return to work or school tests will likely be deemed non-medical, and it is unlikely that such testing would qualify for coverage with these plans.

If insurance coverage of a coronavirus test is of concern, then the best option is to call the insurer ahead of time in order to determine whether the test will be covered. Please understand though that if an individual is ill and experiencing coronavirus-like symptoms, then placing a call to inquire about coverage prior to seeking medical treatment is not necessary. As is required by the relevant federal guidance, a test must be covered if it has been ordered by a healthcare provider due to illness.

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