Need a COVID test? Depending on why and your health plan, there may be a fee

Eligibility and requirements for COVID testing have expanded since the early months of the pandemic.

People with symptoms related to COVID or who are considered to be a close contact of someone with confirmed COVID are still recommended to get tested for the virus. But testing may now also be needed for travel, to work or to shorten a quarantine.

Depending on why the individual is getting a test, the test provider, the kind of test, and the individual's health insurer and plan, there may be a cost for the test.

Insurance companies are only required to pay for a COVID test if the individual is symptomatic or has a known or recent exposure to COVID and the test is determined to be medically necessary by a health care provider, according to the Pennsylvania Department of Health's website.

"A testing site may provide free testing or it may choose to collect coverage information and bill insurers or employer health plans for diagnostic tests," Lindsay Bracale, Pennsylvania Insurance Department deputy communications director, said in an email. "Also, testing not based on an individualized clinical assessment, such as for public health surveillance or employment purposes, is not required to be covered by insurance."

Bracale added that the laws regarding the coverage and cost of testing are federal laws, and specify coverage and provider reimbursement requirements for the duration of the federal public health emergency.

Even when the testing is free, hospitals and providers are expected to bill insurance companies for the fees associated with collecting the specimens. Labs are also expected to bill for the actual testing.

According to the U.S. Department of Health and Human Services, no-cost testing is available at local health centers and select pharmacies. However, test providers including the select pharmacies along with the state departments of health and insurance still encourage people to check their health plan to see if testing is covered at no fee and if certain conditions have to be met for the testing to be free such as being determined to be medically necessary.

The laws have not changed in recent months. However, people may be surprised at having to pay for a COVID test as some providers have expanded testing to include tests not determined to be medically necessary.

A map of testing sites and who is currently eligible to be tested at the site is available on the state department of health's coronavirus website under symptoms and testing.

What insurers do and don't cover

Early on in the pandemic, many insurers announced medically appropriate COVID testing would be covered without copays, deductibles or cost-sharing for their members. This was then reinforced by The Families First Coronavirus Response Act and CARES Act.

Insurers have been and will continue to cover COVID tests determined to be medically necessary, meaning individuals are ordered or referred by a health care provider to get tested. One of those insurers is Capital Blue Cross, which serves Berks County including 17 of the county's public school districts.

"Capital Blue Cross will continue to cover the cost of a COVID-19 diagnostic test with no member responsibility for any cost share (such as a copay, coinsurance, or deductible) during the federal public health emergency if the test is performed as a result of a clinical assessment, such as a test ordered by a doctor or other health care provider, or when a provider refers our member for a test," said Jerry Reimenschneider, senior public relations specialist for Capital Blue Cross.

Like other insurers, Capital Blue Cross is not covering the cost of tests that are not determined to be medically necessary.

"Capital Blue Cross does not cover the cost of tests performed for public health monitoring or employment purposes," Reimenschneider said.

An example of a test not determined to be medically necessary is if any employee is required by their employer to be tested every so often in order to work, Reimenschneider added.

The insurance company does not determine if the test is medically necessary.

"A health insurance company is required to cover testing based on an individualized clinical assessment by a health care provider," Bracale said. "Testing for public health surveillance or employment purposes is not required to be covered by insurance. A testing provider may choose to provide free testing, but should not bill the individual for a diagnostic test."

Types of tests

Two different types of COVID tests are available, diagnostic tests and antibody tests.

Diagnostic tests are used to show an active COVID infection. This type of test includes polymerase chain reaction tests and nucleic acid amplification testing, and antigen tests.

Antibody tests are considered non-diagnostic tests and show a past infection. This type of test is used to determine if an individual had a prior exposure to COVID as a result of having antibodies in their immune system that are produced in response to the virus.

Testing offered by pharmacies

Select pharmacies offering no-cost testing in Pennsylvania, according to HHS, include CVS, Rite Aid, Walgreens and Walmart.

The pharmacies suggest individuals check with their insurance company before scheduling a test to confirm the cost of the test will be covered. If an individual has insurance, they will likely need to show their insurance card at their testing appointment.

"Patients with insurance should not have any out-of-pocket costs for a covered COVID-19 test, but you should check with your health plan to confirm before scheduling a test," said Tara Burke, spokesperson for CVS. "You will be responsible for any patient cost share as determined by your insurance. If active coverage cannot be located, your test will be submitted to the federal program for the uninsured for payment."

Walgreens notes that individuals with insurance receiving a diagnostic test will be asked to show their insurance card at the appointment and the lab may bill their insurer.

According to Walmart, there is no cost to individuals for the HHS community testing sites and no-cost testing is available at its testing sites supported by Quest Diagnostics based on eligibility. Those with or without symptoms can qualify for a free test, according to the company.

Self-pay is also available for individuals who do not want to submit the testing to insurance or the government for reimbursement.

Over-the-counter, take-home COVID tests are also available for purchase at the pharmacies.

The best way for an individual to know if their COVID test will be covered or include a cost is to check their health plan and insurer.