On March 18, 2020, the Families First Coronavirus Response Act was signed into law. The law contains a provision (Division F Section 6001) for insurance coverage for the testing of Covid-19. It states that, both group and individual health insurance plans shall (aka must in legalese) provide coverage and must not “impose any cost sharing, including deductibles, copayments, and coinsurance requirements or prior authorization or other medical management requirements…”
Seems simple right? Tests are covered.
Not so fast.
At the very bottom of this same provision it states that coverage for Coronavirus tests during a health care provider visit, urgent care or ER visit, that results in the order of a test will only be covered if it “relate[s] to the furnishing or administration of such product or to the evaluation of such individual for purposes of determining the need of such individual for such product.” This should be fairly straightforward for a provider of health services to document. Your doctor should document that all or part of your visit was so that you could obtain a Covid-19 test.
Seems simple right? Tests are covered so long as I go to a healthcare provider to be evaluated so that I can obtain a test.
Not so fast, again!
Insurance companies are first and foremost concerned with their bottom line. Paying out for these tests is going to be costly. In the billions if coverage for said tests continues to be mandated. As a result, Insurance companies may try to use that second bit of language to claim it must be medically necessary in order for your Covid-19 test to be covered. However, nowhere in the Families First Coronavirus Response Act is the phrase “Medically Necessary” or “Medical Necessity.”
Health Insurance companies use the phrase “Medically Necessary” as both a sword and a shield in order to deny coverage of health services. However, in this case, Federal Law preempts any conflicting contractual language including the language of your health insurance policy. Although, as the article above suggests, we will have to wait and see what both health insurance companies and the federal government does next. In order to protect yourself against a denial, encourage your medical provider to document your need for a test.
What should you do if your Coronavirus test is denied for not being medically necessary?
- Look at your Explanation of Benefits (EoB) to understand why the test was denied;
- Read your policy carefully and understand the appeals process;
- If your insurance is through your employer, ask your HR department for assistance;
- Contact the insurance company directly and appeal your denial;
- Contact your Insurance Commissioner; and/or
- Contact an attorney
See my previous article on Coronavirus Insurance here.
Olivia D. Liggio joined Liggio Law in 2016. Prior to joining Liggio Law, Ms. Liggio was an associate at a top personal injury firm where she concentrated her practice on civil litigation including nursing home negligence, automobile negligence, products liability, and medical malpractice,.