Why Did I Get Billed for a COVID Test?

During the pandemic, many individuals received COVID-19 tests without direct cost due to federal policies. This led to confusion when unexpected bills arrived. Understanding why a charge appears requires examining the test’s circumstances and evolving health coverage. While tests were often free, certain situations or regulation changes could result in a patient owing money. This article clarifies common reasons for receiving a COVID-19 test bill.

Federal Mandates and Insurance Coverage for COVID-19 Tests

During the initial phases of the COVID-19 pandemic, federal legislation aimed to ensure broad access to testing without financial barriers. The Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act mandated that most health plans, including private insurance, Medicare, Medicaid, and even coverage for the uninsured, cover COVID-19 testing and related services without cost-sharing. This meant individuals typically did not pay deductibles, copayments, or coinsurance for these services. Coverage during this period generally applied to tests deemed “medically necessary,” often meaning for symptomatic individuals or those with known exposure to the virus.

The federal Public Health Emergency (PHE) declaration for COVID-19, which underpinned many of these mandates, expired on May 11, 2023. This expiration significantly altered the landscape of test coverage, shifting from broad federal requirements to individual insurer policies and standard healthcare rules. After this date, the expectation of completely free testing largely ceased for many, as coverage reverted to pre-pandemic norms. While some plans might continue to offer full coverage, others now apply standard cost-sharing rules, including copays, deductibles, and coinsurance, for COVID-19 tests.

Scenarios Leading to a Bill for a COVID-19 Test

Even during the federal mandates, and especially after the Public Health Emergency ended, several scenarios could lead to an individual receiving a bill for a COVID-19 test.

Non-Medical Purposes

Tests obtained for non-medical purposes, such as those required for travel, employment, school attendance, or general public health surveillance, often fell outside the scope of mandated free coverage. Employers requiring testing might be responsible for covering these costs, but the patient could still receive the initial bill.

Out-of-Network Providers

Utilizing out-of-network providers for testing could also result in a bill, even when federal mandates were in place. While the CARES Act aimed to prevent balance billing for the test itself by requiring insurers to pay out-of-network providers their cash price, related services might not have been fully protected. Patients could still face balance billing for ancillary services provided by an out-of-network facility, such as an urgent care visit or emergency room charges, even if the COVID-19 test itself was covered. This practice could leave patients responsible for the difference between what the provider charged and what the insurer paid.

Administrative and Facility Fees

Administrative fees or separate facility charges also contribute to unexpected bills. While the actual laboratory test might have been covered at no cost, separate fees for specimen collection, urgent care facility use, or a physician’s visit could be billed to the patient. These charges are distinct from the test itself and may not have been subject to the same no-cost-sharing mandates. Some administrative fees for tests could range around $100 or more, adding to the overall cost.

Over-the-Counter and Non-Medically Necessary Tests

Certain types of tests, like over-the-counter (OTC) at-home tests, had specific coverage rules. While plans were generally required to cover up to eight OTC tests per month per individual, this often came with a reimbursement limit, such as $12 per test, if not purchased through a preferred network. Tests not authorized by a healthcare provider or those that did not meet specific medical necessity criteria might also not have been covered. Individuals without insurance faced varying costs, with PCR tests ranging from $25 to $300 and antigen tests from $10 to $200, depending on the provider and location. Even with federal programs available for the uninsured, some costs could still be incurred.

Post-PHE Coverage Changes

Following the expiration of the Public Health Emergency in May 2023, coverage for COVID-19 tests largely reverted to standard health insurance benefits. This means that tests are now typically subject to deductibles, copayments, and coinsurance, similar to other laboratory services or office visits. Patients should expect to pay their usual out-of-pocket costs based on their specific health plan’s terms. This shift represents a significant change from the period of mandated free testing.

Reviewing Your Bill and Explanation of Benefits

Before taking any action regarding a COVID-19 test bill, carefully review all documentation received from both the healthcare provider and your insurance company. The Explanation of Benefits (EOB) from your insurer is a crucial document, detailing how your claim was processed; it is not a bill. An EOB typically includes the date of service, the provider’s name, specific service codes (known as CPT codes), the total amount billed by the provider, the amount your insurer covered, and the amount you might owe. It also lists any reasons for denial or partial coverage.

Healthcare providers use Current Procedural Terminology (CPT) codes to describe the services rendered, such as 87635 for a PCR test or 87426 for an antigen test. Diagnosis codes, like ICD-10-CM code U07.1 for a confirmed COVID-19 diagnosis or Z20.822 for suspected exposure, explain the medical reason for the test. Your provider’s bill should itemize these charges, including CPT and ICD-10 codes, the date of service, and the total amount due. Comparing the provider’s bill directly with the EOB is an essential step. You should check for consistency in dates of service, the specific services performed, and the amounts billed and covered. Any discrepancies or services you do not recognize should be noted.

Actions to Take Regarding a COVID-19 Test Bill

Once you have thoroughly reviewed your bill and Explanation of Benefits (EOB), the next step is to initiate communication with the relevant parties. Begin by contacting the billing department of the healthcare provider or laboratory that issued the bill. You can inquire about specific charges, request a detailed itemized bill if you haven’t received one, and understand their billing policies. This conversation can often clarify misunderstandings or identify potential coding errors.

Next, contact your insurance company to discuss the EOB and any denial reasons. Be prepared to reference specific details from your EOB, such as the date of service, provider name, and the denial code. If you believe the test should have been covered, you can initiate an appeal process with your insurer, providing any additional information they may require. Many states offer consumer assistance programs through their insurance departments or consumer protection agencies, which can provide guidance or mediate disputes if issues persist.

Patient protections, such as those under the No Surprises Act, may apply in certain situations. This federal law generally protects patients from unexpected medical bills from out-of-network providers for emergency services and certain non-emergency care delivered at in-network facilities. While its primary focus is not solely on COVID-19 tests, it could be relevant if the test was part of emergency care or an unexpected out-of-network charge. If the bill is determined to be legitimate and owed, you can discuss payment options with the provider, such as payment plans or potential financial assistance programs.