The importance of COVID-19 testing is clear, especially as new cases climb dramatically, reversing earlier successes at controlling the spread of the disease. Lack of a coordinated, federally-led testing initiative and protocols has prompted questions about how often testing should occur, whether both symptomatic and asymptomatic should be tested, and who should pay for it, and in what circumstance.

As states implement their re-opening plans, public health experts recommend increased access to COVID-19 testing and contact tracing before communities return to work and school. The federal government’s Guidelines for Opening Up America Again and Blueprint for Testing Plans and Rapid Response Programs provide limited guidance, and identify states as responsible for developing testing plans and rapid response programs.

Federal guidance recommends that:

• Every symptomatic patient should receive a timely and accurate test.
• Selected monitoring of rates should occur at senior and congregate living settings, federally supported health care clinics, and other high-priority locations identified by states, such as food processing plants. Priority should be given to underserved, urban and tribal settings.
• Antibody tests should be available for first responders, essential workers, health care providers, and vulnerable populations.
• Federal guidelines also suggest states not begin reopening their economies and loosening stay-at-home orders, etc., until there is a downward trajectory of documented cases, or a downward trajectory of positive tests (as a percent of total tests) within a 14-day period. 

However, there is no nationally recognized, evidence-based testing protocol available for states and/or employers to adapt or model their own testing approaches on. 

What should the frequency of testing be to safely re-engage staff and open a business? Importantly, guidance to date does not address testing the asymptomatic, yet research shows they can transmit the disease – an issue of mounting importance to employers and school officials as they contemplate when and how to resume classes. Confidence in a testing protocol could alleviate concerns for educators and families, paving the way for a thoughtful approach to schooling youth, which would also allow parents more freedom to go back to work.  

Other countries have shown that case identification and contact tracing are vital to limiting the spread of COVID-19. Experts recommend that the United States should conduct more than 900,000 tests a day, with the goal of reducing the positive rate to less than 5 or 10 percent before reopening. On June 22, 2020, the COVID Tracking Project reported 464,758 new tests performed nationwide, and the Centers for Disease Control and Prevention (CDC) reported a positive testing rate of 10 percent.

The combination of testing and contact tracing can help identify other potential individuals infected with COVID-19 before it can spread further. Experts recommend that rapid diagnostic testing, contact tracing, and the ability to isolate new cases are important rapid response operations. Research shows that these testing, contact tracing, and isolation strategies are more effective at reducing transmission than social distancing alone, and are essential for economic and social activities to resume. Congress recently allocated $11 billion  to the CDC to support state, local, and tribal governments to expand testing. Participating jurisdictions will submit a plan to the Department of Health and Human Services that includes testing goals, monthly estimates of laboratory and testing capacity, and a description of how the resources will be used for testing and community mitigation policies. 

The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief and Economic Security Act (CARES Act) also allocate funds to expand the availability of COVID-19 testing with the intention that individuals can access testing for free. Through these laws, Congress earmarked dollars within provider relief funds for testing and treatment for the uninsured and created a new Medicaid COVID-19 testing eligibility group that can be implemented as a state option. The laws also include requirements that group health plans and individual insurance cover COVID-19 testing with no cost-sharing or medical management requirements, such as prior authorization. 

Health insurers are required to cover tests “when medically appropriate for the individual, as determined by the individual’s attending health care provider.” An attending provider is defined by federal guidance as a licensed provider, practicing within the scope of his/her license, who has made an individual clinical assessment to determine if a COVID-19 test is necessary, but does not need to be “directly” responsible for a patient’s care. In keeping with the intent to expand testing, insurers are required to adopt this looser standard (as compared to the commonly used medical necessity standard) in order to qualify for reimbursement. The federal guidance falls short of explaining what may qualify as “medically appropriate,” so it is unclear how a provider decides who gets a test that is paid for by an insurer. It is assumed those with symptoms will get provider-approved testing that the individual’s health insurance will cover. But what about the individual who has had a contact with someone diagnosed with COVID-19 – does that meet the standard of medically appropriate? Or should testing for this person be part of a state’s public health contact tracing and testing, which is outside the scope of health insurance coverage? 

Federal law and subsequent guidance further require that these health insurers cover out-of-network testing provider claims at the provider’s publicly posted cost, which has been reported as high at $2,315 per test. While most providers charge between $50 to $200 and Medicare reimburses $100 for COVID-19 tests, state employee health plan (SEHP) administrators have reported extreme claims in excess of $1,000 for some of their members’ tests. Such high cost claims are unsustainable, particularly for SEHPs that are impacted by the states’ budget crises caused by the economic downturn, especially if individuals need multiple tests.  

Although the federal guidance released June 23, 2020, did not provide health insurers with cost containment options for out-of-network testing claims, it does address testing in workplaces.  Group health plans and individual insurance coverage are not required to reimburse testing costs for public health surveillance or employment purposes. The guidance notes that “testing conducted to screen for general workplace health and safety,” such as employee “return to work programs,” is beyond its scope of law’s requirement of health insurers. This will come as a relief to SEHPs that have received multiple testing claims for employees’ dependents who are required by their employers to get daily tests. However, it raises anew the question of who will pay for tests? Understanding it is outside the scope of health insurers, is it the direct responsibility of individual employers or can federal funds allocated to states for their public health efforts be used for employment testing? Complicating the issue further, the guidance does not address how often testing should occur for individuals returning to work or if there is a specifically recommended frequency of testing for particular jobs, raising issues for the health of individuals and financial responsibility of employers.

Without clear guidance on the level of testing needed, it is unclear if the existing Congressionally allocated funding is enough, even with the requirement that health insurers further subsidize testing. The lack of an evidence-based testing protocol could put the public’s health at risk and undermine state efforts to reopen their economies. While states have already made strides to establish comprehensive contact tracing, these efforts could be further enhanced by nationally coordinated testing efforts. And, without some federal guidelines on COVID-19 testing rates, reimbursements for extremely expensive provider tests could be a driver of health costs for some insurers.