Amid ongoing concern about the new coronavirus, Vice President Mike Pence sought to assure Americans that their health insurance will cover the tests needed for diagnosis.
鈥淲ith regard to the cost, let me be very clear: HHS has designated the coronavirus test as an essential health benefit. That means, by definition, it鈥檚 covered in the private health insurance of every American, as well as covered by Medicare and Medicaid.鈥�
That got us wondering about Pence鈥檚 assurance. Can he really claim that this designation means that all Americans with private health insurance, Medicare and Medicaid will be covered?听 And, is there a difference between coverage and cost?
First, what are 鈥渆ssential benefits鈥� and why does that matter?
We reached out to the vice president鈥檚 office for details about his comments but got no reply.
Next, we consulted with a range of experts, who helped us fill in the blanks.
鈥淭here are many things wrong with the statement,鈥� said Christen Linke Young, a fellow with the USC-Brookings Schaeffer Initiative for Health Policy.
For one thing, many Americans鈥� insurance policies don鈥檛 have to include coverage of essential health benefits, but more on that later. Still, as Young and other experts helped us piece together the details, it became increasingly clear that this testing will ultimately be covered by most Americans鈥� health insurance. But, it is not a simple process 鈥� the actual cost to patients is the biggest uncertainty 鈥� and making it happen will require steps not only by the federal government, as Pence suggested, but also by state regulators and private insurers.
Let鈥檚 Start With The Basics
Under the Affordable Care Act, insurance plans covering individuals and small employers must provide coverage of 10 essential health benefits (EHBs), including prescription drugs, maternity care, hospital care and laboratory services.
Lab services could include diagnostic tests for, say, influenza, strep throat or even coronavirus. But there isn鈥檛 a master list of all the tests covered.
鈥淭hey don鈥檛 say we only cover these particular diagnostic tests,鈥� said Young. 鈥淚t鈥檚 a broad category of coverage.鈥�
So HHS probably does not have to designate the COVID-19 test as an EHB for it to be covered. HHS did not respond to a question from us about whether it had, indeed, designated coronavirus testing as an EHB.
States, because they regulate insurers within their borders, are also weighing in to add clarity. and, for example, have ordered insurers to cover coronavirus testing and waive patient costs.
听It also should be noted that Pence鈥檚 invoking of EHBs relies on the ACA, even as the administration has been a constant and staunch opponent of the law.
鈥淭he irony is great with this coming from an administration that has done everything it can to repeal the ACA, roll back essential health benefits and promote short-term plans that don鈥檛 cover much,鈥� said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University.
But there鈥檚 another, bigger catch: EHBs apply only to a limited number of 鈥� those ACA-compliant plans purchased by individuals and small employers, which are defined as businesses with fewer than 50 employees.听听听
The requirements don鈥檛 apply to many workplace plans (including those provided by large businesses and), even though most Americans 鈥� 鈥� who have health insurance get it through their job.
Most of these plans, though, do cover a wide range of benefits, including laboratory services, but they are not required by law to do so.
Coronavirus testing would likely be lumped in, especially as 鈥�employers likewise very much want COVID under control and do not want it spreading through their workforces,鈥� said James Gelfand, senior vice president at the ERISA Industry Committee, which represents large employers.
Private insurers are beginning to move in this direction, too., the industry鈥檚 lobbying group, said in early March its members will cover diagnostic testing when ordered by a physician and will 鈥�take action to ease network, referral, and prior authorization requirements and/or waive patient cost sharing.鈥�
And what about Americans who have purchased alternative forms of insurance?
The ACA鈥檚 rules 鈥� including those on essential benefits 鈥� don鈥檛 apply to several types of insurance that the Trump administration has promoted, including short-term plans. Such plans have lower premiums than ACA plans, mainly because they don鈥檛 have to offer a wide range of benefits or meet other ACA rules. Consumers should 鈥渞ead the fine print to see what is in and what is out,鈥� said Corlette.
Short-term plans also can cap annual treatment payment amounts, reject people with medical conditions 鈥� or review their medical records after they make a claim to see if they had a preexisting condition that could disqualify them for coverage.
Meanwhile, EHB rules don鈥檛 apply to Medicare. But that federal health insurance program for seniors and the disabled has made clear on its website that it will cover the , saying, 鈥�This test is covered when your doctor or other health care provider orders it, if you got the test on or after February 4, 2020.鈥�
The agency that oversees , the state-federal low-income health insurance program, issued a release saying that 鈥渢esting and diagnostic services are commonly covered鈥� and that lab tests are a 鈥渕andatory benefit.鈥�
But Does Coverage Mean The Tests Will Be Free Or Low-Cost?
No, coverage and cost are not the same.
And that鈥檚 the key issue for policy and health experts.
For those who have not yet hit their annual deductible, 鈥�the full cost of diagnostic tests will fall on those who get them,鈥� said Nicholas Bagley, a professor at the University of Michigan Law School. 鈥淭hat will discourage some people from getting tested in the first place, which is a public health nightmare.鈥�
Many private plans, both those offered by employers and those purchased by individuals, include deductibles that enrollees must meet before full coverage kicks in. Even after a deductible is satisfied, many plans also require some sort of copayment 鈥� be it $10, $25 or more 鈥� when seeing a doctor or going for a lab test. For emergency room visits, the cost sharing is higher.
If insurers don鈥檛 waive cost sharing for the test, it could be an issue for some consumers.听听
Still, Bagley said, the federal government is limited in its ability to order insurers or employers to waive patient payments, at least in the short term. Longer term, federal officials could seek to declare the tests 鈥減reventive services,鈥� like mammograms or vaccines, which are free for insured patients. But that process would take more than a year to implement.
In the meantime, it鈥檚 mainly up to insurers and employers to decide what to do. Cigna has announced it will waive patient costs for testing 鈥� and others may soon as well, given AHIP鈥檚 statement. Another group, the Alliance of Community Health Plans, which represents nonprofit plans, didn鈥檛 specifically say its members would waive fees but pledged to 鈥渆nsure affordability is not a barrier to the individuals who are recommended for testing by their doctor or a public health authority.鈥�
Our Ruling
Pence said 鈥淗HS has designated the coronavirus test as an essential health benefit. That means, by definition, it鈥檚 covered in the private health insurance of every American, as well as covered by Medicare and Medicaid.鈥�
There are a number of moving parts to this statement, but it tends to leave out important details. For instance, many private and employer health plans have flexibility about what benefits they cover and what consumers will pay. In addition, coverage does not necessarily mean low cost.听听
Bottom line: The idea that 鈥渆veryone who has private insurance will be covered for this testing鈥� is an overstatement. It fails to acknowledge the need for action at the state level and from the private sector, too.
For these reasons, we rate this claim as Half True.听听