Monday, June 1, 2020

Insurers, HMOs Called on to Cover Covid-19 Testing, Treatment Without Charge

By on March 30, 2020

X-ray showing Pneumonia (CDC)

Bill Ensuring Free Virus Care on Puerto Rico Governor’s Desk

SAN JUAN – Both the Puerto Rico Patients Advocate Office and Insurance Commissioner’s Office have issued press releases reiterating that health insurance companies and health maintenance organizations must cover Covid-19 testing without charging copays and deductibles, adding that pre-authorizations and referrals cannot be required for hospitalization and emergency services to treat the infectious virus.

However, it is not clear yet how the testing and treatment costs for the novel coronavirus disease would be covered for patients without insurance, Medicare or enrollment in the Medicaid-backed Vital program. Legislation to cover this gap was passed by the legislature last week and has been sent to Gov. Wanda Vázquez for enactment.

“The insuring entity is obligated to satisfy the totality of the payment for Covid-19 tests, guaranteeing this way that patients receive the service without cost,” Puerto Rico Patients Advocate Edna Díaz de Jesús said in a statement, referring to Normative Letter On. CN-2020-269D, issued March 11 by the island’s insurance industry regulator. “It clearly states the obligation of insurers to provide coverage of Covid-19 tests, according to medical criteria.”

Moreover, the Families First Coronavirus Response Act, signed by President Trump on March 18, also mentions this requirement for insurance companies that underwrite private group and individual plans, which must cover Covid-19 testing without charging copays, Díaz said.

“We remind our patients that they have the right to get a receipt when making total or partial payment to [medical] services providers,” she said, calling on patients confronting problems or in need of guidance to email her at “Our efforts are centered on contributing to contain the spread of this virus and, therefore, mitigate its impact.”

For his part, Puerto Rico Deputy Insurance Commissioner Rafael Cestero, reiterating the directives in the March 11 normative letter, said that health maintenance organizations and insurers underwriting commercial medical plans must ensure all covered patients “opportune access to the health services necessary to address the diagnosis and treatment” of Covid-19.

He said medical plans cannot establish requirements pre-authorization or service utilization management requirements when dealing with Covid-19 patients.

Clinical lab testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes the Covid-19 disease, is included in medical plans’ mandated essential health benefits, which include other laboratory services, X-rays and diagnostic tests, Cestero said, adding that such testing must be covered without charge when “medical criteria so orders to do the tests.”

Doctors and other medical professionals on the island have urged Vázquez to order more Covid-19 testing kits, saying the number of tests being performed is not enough to track and curb the fast-moving disease. The head of the governor’s Covid-19 task force, Dr. Segundo Rodríguez, said Thursday that Some 200,000 rapid coronavirus testing kits could arrive Sunday, although he acknowledged that Puerto Rico competes with many countries to get the tests, which has made delivery difficult.

“In accordance with the priorities of Gov. Wanda Vázquez Garced, these measures are needed to guarantee that patients receive the necessary health services, free of the barriers that could restrict access,” Cestero said in a statement, adding that more information on the matter can be obtained on the agency’s website,, or by calling (787) 304-8686. “Making available the Covid-19 diagnostic test free of charge to all of the population is a significant determining factor to encourage people to seek out medical intervention in time, which has a positive impact on the health of the individual and the decrease in the possibility of the spread of the coronavirus.”

Puerto Rico Deputy Patients Advocate Dr. Alexis Lugo told Caribbean Business that the agencies reiterated their messages because “some clinical laboratories may not have understood the previous communications” issued by the agencies.

“The press release was issued because the patients’ advocate received a call from Rep. Juan Oscar Morales, who is vice chairman of the House Health Committee, about a clinical lab that was charging $20 for a Covid-19 testing kit,” he said. “So the patients’ advocate issued a clarification that you cannot charge for the kit. There should be no interruption in terms of the testing.”

Lugo said that as of Friday, no patient had filed a complaint in his office for noncompliance with Covid-19 coverage directives. He said he had heard a news outlet reporting that a representative of a clinical lab had said they would charge for processing Covid-19 test samples.

Nevertheless, the agency directives do not mention the testing and treatment of Covid-19 patients who may be uninsured or underinsured. The number of medically uninsured people in Puerto Rico was close to half a million, or about 15 percent of the population in 2018, according to the latest U.S. Census Bureau Community Survey data.

Many more people could lose coverage due to layoffs resulting from the governor’s order to close non-essential business facilities.

Lawmaker approval

The commonwealth’s Legislative Assembly passed last week House Bill 2442, submitted by House Speaker Carlos “Johnny” Méndez, which would ensure that Covid-19 patients are not charged for tests, treatments and hospitalizations, whether they have insurance or not. The bill, which is waiting for the governor’s signature, would ban insurers from charging coronavirus patients deductibles and copays for disease diagnosis and treatment. The legislation would also allow medical providers, hospitals and ambulance companies to get reimbursed by medical plans for all costs related to the diagnosis and treatment of the respiratory virus, which has spread throughout the world, infecting nearly 750,000 people and killing more than 35,000.

More than 127 people in Puerto Rico had tested positive for the virus and five had died as of Sunday.

The clinical labs must apply for reimbursement from the health insurance companies, Lugo said, adding that if a patient does not have coverage, this should not be a reason for denying testing and treatment.

“There is a process of documenting this cost so that, once the government establishes a reimbursement protocol for this, it can be done,” he said. “The clinical lab must document the cost and a reimbursement request would be sent to the government. How is this going to be done? A mechanism has to be established. There is a bill that has yet to be signed.”

The public can also get free Covid-19 testing at 330 primary medical centers, funded by a combination of federal and local funding, Lugo said. People who are uninsured or partially insured, including non-U.S. citizens, can go to these centers to get evaluated for a minimum cost or for free in the case of people with low incomes, he said.

Lugo said Covid-19 does not qualify for special catastrophic treatment coverage under Act 150 of 1996 because only 16 specified conditions are included in this program. HIV/AIDS is the only virus-related condition covered by this act, he said.

To qualify for publicly funded Vital coverage, patients’ economic eligibility would have to determined, Lugo said. He said the office had not made an estimate on how much an average Covid-19 treatment might cost.

“That would depend on medical criteria,” he said, urging those who test positive for the virus to call the special hotline set up by the Health Department to receive guidance on where to get treatment: (787) 999-6202.

While a majority of Covid-19 patients will only get mild symptoms and just require home rest, about 6 percent of cases could require hospitalization due to complications caused by the virus, such as pneumonia and, according to some reports, heart failure.

An analysis issued last week by the Kaiser Family Foundation estimates that the average cost of treatment stateside for someone with insurance could be about $9,763, but could reach to climb to around $20,292 if there are complications. The claims-based study by Peterson-KFF Health System Tracker used typical spending for hospital admissions for pneumonia in 2018 as a proxy for Covid-19.

Based on admissions for three diagnosis-related groups (DRGs) for pneumonia, the researchers found that the average cost of an admission for pneumonia with major complications and comorbidities was $20,292. For patients with less serious complications or comorbidities, the average was $13,767, and for those without any complications or comorbidities $9,763. The analysis was limited to people under age 65 and used employer health plan claims for fewer than 18 million people.

Another brief issued last week by New York-based FAIR Health, an independent nonprofit that collects health-related data, estimated that treating a Covid-19 patient with major complication or comorbidity could reach $74,310.

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