Trump using ACA to ensure COVID19 testing & coverage while suing to strike down...ACA.
Last week it was noted by several healthcare policy experts that if and when a vaccine for the coronavirus (COVID-19) sweeping the entire planet is ever developed, under the Affordable Care Act, insurance companies would be legally required to cover the full cost of it for anyone enrolled in an ACA-compliant policy:
SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
(a) In General.--A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for--
(1) evidence-based items or services that have in effect a rating of 'A' or 'B' in the current recommendations of the United States Preventive Services Task Force;
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and
(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.
(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.
(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.
In other words, the moment the Advisory Committee makes such a recommendation about COVID-19 (which they damned well should), it would automatically have to be covered at zero cost-sharing by insurance carriers. Of course, that's sadly still theoretical at the moment, as there is no such vaccine as of yet and likely won't be for at least a year or more.
As for testing for coronavirus, this was released last week by the Centers for Medicare & Medicaid. The last paragraph below should be of special interest:
CMS Develops Additional Code for Coronavirus Lab Tests
- Agency Issues Fact Sheets Detailing Coverage under Programs
Today, the Centers for Medicare & Medicaid Services (CMS) took additional actions to ensure America’s patients, healthcare facilities and clinical laboratories are prepared to respond to the 2019-Novel Coronavirus (COVID-19).
CMS has developed a second Healthcare Common Procedure Coding System (HCPCS) code that can be used by laboratories to bill for certain COVID-19 diagnostic tests to help increase testing and track new cases. In addition, CMS released new fact sheets that explain Medicare, Medicaid, Children’s Health Insurance Program, and Individual and Small Group Market Private Insurance coverage for services to help patients prepare as well.
“CMS continues to leverage every tool at our disposal in responding to COVID-19,” said CMS Administrator Seema Verma. “Our new code will help encourage doctors and laboratories to use these essential tests for patients who need them. At the same time, we are providing critical information to our 130 million beneficiaries, many of whom are understandably wondering what will be covered when it comes to this virus. CMS will continue to devote every available resource to this effort, as we cooperate with other government agencies to keep the American people safe.”
HCPCS is a standardized coding system that Medicare and other health insurers use to submit claims for services provided to patients. Last month, CMS developed the first HCPCS code (U0001) to bill for tests and track new cases of the virus. This code is used specifically for CDC testing laboratories to test patients for SARS-CoV-2. The second HCPCS billing code (U0002) announced today allows laboratories to bill for non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19). On February 29, 2020, the Food and Drug Administration (FDA) issued a new, streamlined policy for certain laboratories to develop their own validated COVID-19 diagnostics. This second HCPCS code may be used for tests developed by these additional laboratories when submitting claims to Medicare or health insurers. CMS expects that having specific codes for these tests will encourage testing and improve tracking.
The Medicare claims processing systems will be able to accept these codes starting on April 1, 2020, for dates of service on or after February 4, 2020. Local Medicare Administrative Contractors (MACs) are responsible for developing the payment amount for claims they receive for these newly created HCPCS codes in their respective jurisdictions until Medicare establishes national payment rates. Laboratories may seek guidance from their MAC on payment for these tests prior to billing for them. As with other laboratory tests, there is generally no beneficiary cost sharing under Original Medicare.
To ensure the public has clear information on coverage and benefits under CMS programs, the agency also released three fact sheets that cover diagnostic laboratory tests, immunizations and vaccines, telemedicine, drugs, and cost-sharing policies.
Medicare Fact Sheet Highlights: In addition to the diagnostic tests described above, Medicare covers all medically necessary hospitalizations, as well as brief “virtual check-ins,” which allows patients and their doctors to connect by phone or video chat.
Medicaid and Children’s Health Insurance Program (CHIP) Fact Sheet Highlights: Testing and diagnostic services are commonly covered services, and laboratory and x-ray services are a mandatory benefit covered and reimbursed in all states. States are required to provide both inpatient and outpatient hospital services to beneficiaries. All states provide coverage of hospital care for children and pregnant women enrolled in CHIP. Specific questions on covered benefits should be directed to the respective state Medicaid and CHIP agency.
Individual and Small Group Market Insurance Coverage: Existing federal rules governing health insurance coverage, including with respect to viral infections, apply to the diagnosis and treatment of with Coronavirus (COVID-19). This includes plans purchased through HealthCare.gov. Patients should contact their insurer to determine specific benefits and coverage policies. Benefit and coverage details may vary by state and by plan. States may choose to work with plans and issuers to determine the coverage and cost-sharing parameters for COVID-19 related diagnoses, treatments, equipment, telehealth and home health services, and other related costs.
Yes, that's right "existing federal rules" means...the Affordable Care Act. In other words, the only reason people enrolled in ACA policies are protected from having to pay out of pocket for coronavirus test costs is thanks to the ACA:
Diagnostics & Laboratory Services
Laboratory services are a category of Essential Health Benefits (EHB) that individual and small group market issuers are generally required by law to include in their benefit packages. However, whether any particular diagnostic or laboratory service is covered by a plan varies, and is based on the specific benchmark plan selected by each state and the terms of the plan. Large group market plans and self-insured plans are not subject to EHB coverage requirements. You should check with your health insurance company to determine coverage for lab tests and related services for the diagnosis and treatment of COVID-19. Standard cost sharing may apply for these services.
If a vaccine is developed for COVID-19 and approved for use by the FDA, further guidance may be issued regarding whether the vaccine would need to be covered as a preventive service for which no cost sharing would be charged.
Hospitalization & Ambulatory Patient Services
Hospitalization, ambulatory patient, and emergency services are categories of EHB that individual and small group market issuers are generally required by law to include in their benefit packages. However, whether any particular hospitalization, ambulatory patient, or emergency service is covered by plans varies, and is based on the specific benchmark plan selected by each state and the terms of the plan. Large group market plans and self-insured plans are not subject to EHB coverage requirements. You should check with your health insurance company to determine coverage for physician and hospital related services for the diagnosis and treatment of COVID-19. Standard cost sharing may apply for these services.
Telehealth services or home health visits may already be covered by many health insurance companies. You should check with your health insurance company to determine whether these services are covered and whether any cost-sharing requirements apply.
Prescription drugs are a category of EHB that individual and small group market issuers are generally required by law to include in their benefit packages. However, whether any particular prescription drug is covered by plans varies and is based on the specific benchmark plan selected by each state and the terms of the plan. Prior authorization for prescription drugs, including for any treatment for COVID-19 that may become available, may still apply, so you should check with your health insurance company to clarify any future changes to prior authorization requirements. Plans and issuers may elect to apply prior 1 3/5/2020 authorization for treatment and or refills flexibly, as circumstances warrant. Large group market plans and self-insured plans are not required to cover EHBs, so coverage would depend on the terms of the plan.
Under federal law, for most health plans and health insurance coverage, if your health plan refuses to pay a claim or ends your coverage, you have the right to appeal the decision to the health plan and, if the plan upholds its denial, you have the right to have that decision reviewed by a third party. In urgent situations, a health plan must make a decision within 72 hours, or less, depending on the medical urgency of the case. Your explanation of benefits (EOB) and plan documents should have instructions on how to appeal a denied claim. If you aren’t currently enrolled in coverage, you can see if you qualify for a Special Enrollment Period to enroll in a private health plan through HealthCare.gov. As a reminder, federal law and regulations provide protections against preexisting condition exclusions in health insurance coverage. Health plans must permit you to enroll regardless of health status, age, gender, or other factors that might predict the use of health services. Marketplace plans may not terminate coverage due to a change in health status, including diagnosis or treatment of COVID-19. CMS remains firmly committed to maintaining protections for all Americans with pre-existing conditions.
EVERYTHING IN YELLOW ABOVE is only the case THANKS TO THE PATIENT PROTECTION & AFFORDABLE CARE ACT.
The very same Patient Protection & Affordable Care Act (or ACA for short) which the Trump Administration is asking the Supreme Court to strike down this year.
Put more simply:
Your daily reminder that:
a. Trump is using a provision of the Affordable Care Act to require that insurers cover the Coronavirus test.
b. Trump is in court right now trying to invalidate the entirety of the Affordable Care Act.
— Chris Murphy (@ChrisMurphyCT) March 9, 2020