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.

How Berks providers are handling testing

The types of tests available, who is eligible, and handling of cost for the tests differ from provider to provider, in addition to the individual's own health plan.

Tower Health offers COVID tests for symptomatic and asymptomatic individuals. Rapid antigen and PCR lab tests are offered at all Tower Health Urgent Care locations while rapid PCR tests are currently offered at select urgent care locations including Exeter and Wyomissing.

The rapid antigen test is available for symptomatic patients and those qualifying for antibody infusion therapy. The PCR and rapid PCR tests are available for those with or without COVID symptoms.

Individuals are not required to have a doctor's order or approval from their insurance company to get tested, according to Dr. Charles Barbera, vice president for pre hospital and unscheduled care at Tower Health. Those without a doctor's order will be evaluated prior to testing to determine if a test is warranted and what type of test.

"Tower Health will process PCR lab tests through insurance for most testing scenarios, with no additional payment required," Barbera said. "However, cost-share waivers are set by each health insurance company and are subject to change. There is a $150 out of pocket fee for the rapid RT-PCR test."

Barbera added that the health system has ordered additional testing machines and supplies to continue to meet the needs of patients and communities as the delta variant has increased infections.

"The COVID virus is still in our communities and positive cases, hospitalizations and deaths are continuing to rise in our region and across the country," Barbera said. "Tower Health encourages all eligible persons to get vaccinated against COVID-19 as soon as possible. The vaccine is safe and effective in discouraging the spared of the virus, limiting symptoms, and preventing hospitalization and death."

Penn State Health is offering testing for individuals experiencing symptoms at its testing sites.

"Multiple Penn State Health locations are offering symptomatic COVID-19 testing by appointment only," said Barbara Schindo, a spokesperson for Penn State Health. "Patients should reach out to their primary care provider or use Penn State Health OnDemand to discuss symptoms and determine whether they need testing."

Testing sites include Penn State Health St. Joseph's urgent cares in Maidencreek Township and Strausstown as well as the hospital's downtown campus. Additional locations in Berks include Penn State Health – Exeter Ridge Family Practice, Penn State Health Medical Group – Downtown Family Practice, Penn State Health Medical Group – Downtown Pediatrics and Penn State Health Medical Group – All About Children.

A copay is collected at the testing appointment, according to the health system's coronavirus information website.

"COVID testing is submitted to the patient's insurance," Schindo said.

Lehigh Valley Health Network provides testing for symptomatic and asymptomatic individuals, though a prescription is required to be tested. The health system states on its website that most insurance companies have waived cost-sharing for testing for symptomatic individuals though there are some exceptions based on individual polices.

As for testing for asymptomatic individuals, the health system states the individual will likely be responsible for any fees associated with getting the test.

Geisinger Health offers COVID testing by appointment for individuals who are symptomatic, have been in close contact with someone with confirmed COVID or need a test for travel.

The travel test is self-pay as such tests are often not considered to be medically necessary and therefore typically not covered by health insurance. The out-of-pocket cost for a travel test is $140.

As mentioned, health centers are offering no-cost testing. This include the Berks Community Health Center.

The health center is providing testing for the entire community in Reading at 838 Penn St. Testing is by appointment, and individuals need to call for a screening and to register for an appointment.

A referral from a doctor or insurance information is not needed to get a test, said Deborah Hartranft, director of development and communications. All that is needed from the individual at their appointment is a picture ID.

"The testing is free, we do not collect insurance information," Hartranft said. "It is important to get tested for COVID if you have had known recent exposure to a positive case or currently have COVID-19 symptoms."

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.