COVID-19: Patient coverage FAQs

Yes. In addition, Aetna is waiving member cost-sharing for diagnostic testing related to COVID-19. The test can be done by any authorized testing facility. This member cost-sharing waiver applies to all Commercial, Medicare and Medicaid lines of business. The policy aligns with the Families First and CARES legislation and regulations requiring all health plans to provide coverage of COVID-19 testing without cost share. The requirement also applies to self-insured plans. Per guidance from the Centers for Medicare & Medicaid Services (CMS), the Department of Labor and the Department of the Treasury, all Commercial, Medicaid and Medicare plans must cover COVID-19 serological (antibody) testing with no cost-sharing.

Aetna will cover, without cost share, diagnostic (molecular PCR or antigen) tests to determine the need for member treatment.¹ Aetna’s health plans generally do not cover a test performed at the direction of a member’s employer in order to obtain or maintain employment or to perform the member’s normal work functions or for return to school or recreational activities, except as required by applicable law.

Aetna will cover, without cost share, serological (antibody) tests that are ordered by a physician or authorized health care professional and are medically necessary. Aetna’s health plans do not cover serological (antibody) tests that are for purposes of: return to work or school or for general health surveillance or self-surveillance or self-diagnosis, except as required by applicable law. Refer to the CDC website for the most recent guidance on antibody testing.

This policy for diagnostic and antibody testing applies to Commercial, Medicare and Medicaid plans.²

Yes. Prior to COVID-19, testing for infectious diseases were included in the rate for surgical procedures and that policy will continue during the COVID-19 pandemic.

Yes. If the plan provides in and out of network coverage, then the cost-sharing waiver applies to testing performed or ordered by in-network or out-of-network providers. The policy aligns with Families First and CARES Act legislation and regulations requiring all health plans to provide coverage of COVID-19 testing without cost share.

Members should not be charged for COVID-19 testing ordered by a provider acting within their authorized scope of care or administration of a COVID-19 vaccine. Providers can seek reimbursement for uninsured patients through the Health Resources & Services Administration (“HRSA”) for COVID-19 testing, treatment and vaccine administration. This information is available on the HRSA website.

Any COVID-19 test ordered by your physician is covered by your insurance plan.

Also, new federal guidelines allow members with private, employer-sponsored and student health commercial insurance to request reimbursement for over-the-counter COVID-19 diagnostic tests that are purchased on or after January 15, 2022 without physician’s orders¹. This mandate is in effect until the end of the federal public health emergency.
 

As of April 4, 2022, members with Medicare Part B can get up to eight over-the-counter COVID-19 tests each month while the COVID-19 public health emergency lasts. This includes those enrolled in a Medicare Advantage plan. The tests come at no extra cost. Members must get them from participating pharmacies and health care providers. They should check to see which ones are participating. Providers will bill Medicare. You can find a partial list of participating pharmacies at Medicare.gov. Members should take their red, white and blue Medicare card when they pick up their tests.

¹Aetna will follow all federal and state mandates for insured plans, as required.

 

In effort to expand testing capabilities, U.S. Department of Health & Human Services (DHS) authorized pharmacists to order and administer COVID-19 tests, including serology tests, that the FDA has authorized. Pharmacists, in partnership with other health care providers, are well positioned to aid COVID-19 testing expansion.

Routine testing for influenza, strep, and other respiratory infections without a COVID-19 test will be covered subject to applicable cost sharing under the member’s plan.

We cover, without member cost sharing, a same day office, emergency room, or other provider visit at which a COVID-19 test is ordered or administered. If as part of that visit the provider administers or orders a test for influenza, strep, or other respiratory infection, that additional testing will also be covered without member cost sharing.

Tests must be FDA authorized in accordance with the requirements of the CARES Act.

Commercial labs are in the process of updating their provider community about their capabilities and how to order tests. National labs will not collect specimens for COVID-19 testing. Instead, an appropriate specimen should be collected at the health care facility where the patient was seen and the test was ordered or at other non-lab facilities. The specimen should be sent to these laboratories using standard procedures.

Aetna is reaching out to the commercial labs about their ability to provide the COVID-19 testing. The following are some of the national labs approved to do COVID-19 testing(other commercial labs are also approved):

To ensure access for COVID-19 testing and have consistent reimbursement, Aetna will reimburse contracted and non-contracted providers for COVID-19 testing as follows in accordance with the member’s benefit plan³. The following rates are used for COVID-19 testing for commercial and Medicare plans, unless noted otherwise:

Diagnostic testing/handling rates - Medicare

• HCPCS U0001: $35.92 per test
• HCPCS U0002: $51.31 per test
• HCPCS U0003: $100 per test (Commercial plans only)
• HCPCS U0003: $75 per test (Medicare plans only)
• HCPCS U0004: $100 per test (Commercial plans only)
• HCPCS U0004: $75 per test (Medicare plans only)
• HCPCS U0005: $25 per test (Medicare plans only)*
• CPT 0202U: $416.78 per test
• CPT 0223U: $416.78 per test
• CPT 0225U: $416.78 per test
• CPT 0226U: $42.28 per test
• CPT 0240U: $142.63 per test
• CPT 0241U: $142.63 per test
• CPT 86413: $42.13 per test
• CPT 87426: $45.23 per test
• CPT 87635: $51.31 per test
• CPT 87636: $142.63 per test
• CPT 87637: $142.63 per test
• CPT 87811: $41.38 per test
• CPT G2023: $23.46
• CPT G2034: $25.46

Antibody testing rates - Medicare

• CPT 86328: $45.23 per test
• CPT 86408: $42.13 per test
• CPT 86409: $105.33 per test
• CPT 86769: $42.13 per test
• CPT 0224U: $42.13 per test

These reimbursement rates for COVID-19 diagnostic and antibody testing are based on rates announced by CMS. For more information and future updates, visit the CMS website and its newsroom. By submitting a claim to Aetna for COVID-19 testing, providers acknowledge that the above amounts will be accepted as payment in full for each COVID-19 test performed, and that they will not seek additional reimbursement from members.

*As announced by CMS, starting January 1, 2021, Medicare will make an additional $25 add-on payment to laboratories for a COVID-19 diagnostic test run on high throughput technology if the laboratory: a) completes the test in two calendar days or less, and b) completes the majority of their COVID-19 diagnostic tests that use high throughput technology in two calendar days or less for all of their patients (not just their Medicare patients) in the previous month. Laboratories that complete a majority of COVID-19 diagnostic tests run on high throughput technology within two days will be paid $100 per test by Medicare, while laboratories that take longer will receive $75 per test. CMS established these requirements to support faster high throughput COVID-19 diagnostic testing and to ensure all patients (not just Medicare patients) benefit from faster testing. These actions will be implemented under the amended Administrative Ruling (CMS-2020-1-R2) and coding instructions for the $25 add-on payment (HCPCS code U0005).

³Rates above are not applicable to Aetna Better Health Plans. Aetna Better Health plan pricing may be determined by each individual health plan in accordance with its state contracts. Rates may vary for Commercial Plans based on factors such as billed charges or contractual terms.

Aetna generally does not reimburse doctors and dentists for Personal Protection Equipment. PPE, like other disposable infection control supplies, is part of the cost of the underlying procedure.

Aetna participating providers should not bill members for Enhanced Infection Control and/or PPE. If a member is billed for Enhanced Infection Control and/or PPE by a participating provider, he/she should contact Aetna customer service at the phone number listed on the member’s ID card.

Yes, Aetna will cover tests approved, cleared or authorized by the U.S. Food and Drug Administration. Please refer to the FDA and CDC websites for the most up-to-date information. A list of approved tests is available from the U.S. Food & Drug Administration.

At this time, covered tests are not subject to frequency limitations. Subject to applicable law, Aetna may deny tests that do not meet medical necessity criteria.

Based on new federal guidelines, Aetna’s private, employer-sponsored and student health commercial insurance plans will cover up to eight over the counter (OTC) at-home COVID-19 tests per 30-day period for each person covered under your plan. This mandate is in effect until the end of the federal public health emergency.

Note: Each test is counted separately even if multiple tests are sold in a single package. For example, Binax offers a package with two tests – that would count as two individual tests.  As for the eight-test maximum, a family of four covered under the same plan could be reimbursed for up to 32 tests per 30-day period.

Lab-based PCR home collection kits are not covered at this time by the OTC kit mandate.

Refer to the U.S. Food & Drug Administration on tests that are eligible for coverage.

For members with Aetna pharmacy benefits, you can submit a claim for reimbursement through your Aetna® member website.

If your pharmacy benefits are not with Aetna, contact your pharmacy benefits administrator for instructions.

For members with CVS Caremark pharmacy benefits or whose employer covers these tests under medical benefits:

• You should expect a response within 30 days. If your reimbursement request is approved, a check will be mailed to you.

For members with 3rd party PBM:

• Your pharmacy plan should be able to provide that information.

Members with CVS Caremark & members whose plan sponsor is covering under medical.

When you submit your claim, you’ll need to include:

• Who the tests are for (self or dependent)
• The number and type of tests purchased
• Date of purchase
• Price of purchase
• A copy of your receipt

You’ll also be asked to attest that the OTC kit is for personal use only, and not for employment, school, recreational or travel purposes.

For members with 3rd party pharmacy

• Your pharmacy plan should be able to provide that information. (Offer to transfer member to their PBM’s customer service team.)

OTC COVID-19 tests can be purchased at pharmacies, retail locations or online. Due to high demand for OTC at-home COVID-19 tests, supplies may be limited in some areas.

To help improve access to these tests, the Biden-Harris Administration is expanding access to free at-home kits through the federal government. Visit COVIDtests.gov to learn more. 

Aetna is in the process of developing a direct-to-consumer shipping option.

If you have private, employer-sponsored or student health commercial insurance you’re eligible to get reimbursed for over-the-counter at-home COVID kits. You are not eligible if you have Medicare, Medicare Supplement, Medicaid, or voluntary insurance.

• Aetna will cover up to eight (8) over the counter (OTC) at-home COVID-19 tests per 30-day period for each person covered under your plan.
• Note: Each test is counted separately even if multiple tests are sold in a single package. (For example, BinaxNOW offers a package with two tests included – that would count as two individual tests).
• Tests must be approved, cleared or authorized by the U.S. Food and Drug Administration.
• You can only get reimbursed for tests purchased on January 15, 2022 or later.
• These tests don’t require an order from your physician to qualify for reimbursement, although tests ordered by a provider aren’t subject to the frequency limit.
• Tests must be used to diagnose a potential COVID-19 infection. Tests used for employment, school or recreational purposes are not eligible for reimbursement unless required by state law.

Coverage is in effect, per the mandate, until the end of the federal public health emergency.

Your employer or health plan will have the best information on how to buy OTC COVID-19 tests that will be covered.

Some pharmacies may not be able to process claims for OTC COVID-19 tests at the pharmacy counter. If this happens, you can pay for the test, then submit a request for reimbursement.

CVS Health is uniquely positioned to play a vital role in supporting local communities and the overall health care system in addressing the COVID-19 pandemic. Our ability to coordinate the availability of COVID-19 testing bolsters states’ efforts to manage the spread of the virus.

In March, CVS Health opened a pilot drive-through COVID-19 test site in a parking lot at a CVS Pharmacy store in Shrewsbury, MA. This pilot provided the company with a number of key learnings, which helped inform the company’s ability to improve on and maximize drive-through testing for consumers.

In April, CVS Health joined forces with the U. S. Department of Health and Human Services and state governments in Connecticut, Georgia, Massachusetts, Michigan and Rhode Island to help increase access to rapid COVID-19 testing at large-scale sites in publicly accessible areas. Each site operated seven days a week, providing results to patients on-site, through the end of June.

Since then, CVS Health has continued to expand access to COVID-19 testing, establishing testing sites at more than 4,800 CVS Pharmacy locations across the country, including nearly 1,000 of which provide rapid-results testing.

For more information on test site locations in a specific state visit CVS.

Beginning in September 2021, we have added a select number of new testing locations in 10 new states to increase access to COVID-19 testing in high-risk, underserved communities with limited availability to lab testing services. The new states are Alabama, Arkansas, Colorado, Delaware, Iowa, Mississippi, Montana, North Dakota, Oregon and West Virginia.

Testing will not be available at all CVS Pharmacy locations. CVS Pharmacy, HealthHUB^® and MinuteClinic^® will continue to serve customers and patients.

CVS Health currently has more than 4,800 drive –thru testing locations across the country offering COVID-19 testing. Through this effort we are hoping to provide access in areas of the country that need additional testing and are selecting CVS Pharmacy locations with this criteria in mind.

Yes, patients must register in advance at CVS.com to schedule an appointment. Patients will need to pre-register, provide their insurance information as appropriate and verify their eligibility for testing. Once they have registered, the patient will be provided with an appointment window for up to seven days in advance.

For all Aetna-insured Commercial plans, Aetna waived member cost-sharing for inpatient admissions for treatment of COVID-19 or health complications associated with COVID-19 through February 28, 2021. This waiver may remain in place in states where mandated. Self-insured plan sponsors offered this waiver at their discretion.

Aetna will cover treatment of COVID-19 for our Medicare Advantage members. Please note that copays, deductibles and coinsurance will apply according to the member’s benefit plan.

Aetna Better Health will cover the treatment of COVID-19 or health complications associated with COVID-19. Aetna Better Health members with questions about these specific benefits are encouraged to call the member services phone number on the back of their ID cards. This benefit does not apply to Aetna Better Heath of New York, since medical benefits are not covered. Please call your medical benefits administrator for your testing coverage details.

All claims received for Aetna-insured members going forward will be processed based on this new policy. If in-patient treatment was required for a member with a positive COVID-19 diagnosis prior to this announcement it will be processed in accordance with this new policy. In the event a claim has already been processed prior to this policy going into effect, members should contact Customer Service so the claim can be reprocessed accordingly.

No, Aetna will pay the amount of the cost-sharing the member would have ordinarily paid so the provider would receive the same total payment.