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.
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.