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Coverage guidelines for COVID-19 testing
July 23, 2020

Updated November 12, 2020 to clarify the definition of close contact and direct exposure per the Centers for Disease Control.

This article is for all providers caring for our members

Blue Cross Blue Shield of Massachusetts follows federal and state requirements for SARS CoV-2 (COVID-19) testing coverage. This article clarifies when:

  • COVID-19 testing is covered
  • Services associated with testing do not require a cost share

Commercial members: Managed care (HMO and POS), PPO, and Indemnity

Viral testing
Reverse transcription-polymerase chain reaction (RT-PCR) or antigen testing to detect the presence of SARS-CoV-2 for the diagnosis of COVID-19 is covered when ordered by a health care provider who is making an individualized clinical assessment of the patient in accordance with current standards of medical practice This includes the Centers for Disease Control (CDC) and the Massachusetts Department of Public Health (DPH) guidelines.


Covered tests must be approved by the FDA or have Emergency Use Authorization, or the developer must have requested, or intends to request Emergency Use Authorization approval.

In accordance with the Centers for Disease Control (CDC) and the MA Department of Public Health guidelines, covered scenarios include (but are not limited to):

  • Symptoms consistent with COVID-19, such as fever, cough, shortness of breath, chills, muscle pain, sore throat, anosmia, and gastrointestinal distress
  • Asymptomatic patients with direct exposure and/or close contact to another individual with a confirmed case of COVID-19
    • Close contact is defined by the CDC as someone who was within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period* starting from 2 days before illness onset (or, for asymptomatic patients, 2 days prior to test specimen collection) until the time the patient is isolated.
  • Asymptomatic patients who have been identified by contact tracing
  • Symptomatic or asymptomatic patients who require testing prior to a medical procedure or surgery
  • Admission to a facility – including but not limited to a hospital operated or licensed by the Department of Public Health or Mental Health, a long-term acute care hospital, or a skilled nursing facility 

* Individual exposures added together over a 24-hour period (e.g., three 5-minute exposures for a total of 15 minutes).

Covered testing sites include (but are not limited to):

  • Drive-through testing sites
  • Emergency rooms
  • Medical provider offices
  • The patient’s home (using a testing kit—a patient self-swab)

What’s not covered
PCR or antigen testing to detect SARS-CoV-2 is not covered in the following scenarios:

  • General screening purposes such as
    • return-to-work
    • clearance to travel
    • to attend school, day care or camp
    • for public health or surveillance purposes
    • for periodic or serial testing of asymptomatic high-risk individuals (examples include congregate housing and occupational safety)
  • Tests that have been denied FDA approval, an Emergency Use Authorization from the FDA, or laboratories that have not submitted an Emergency Use Authorization request within a reasonable timeframe
  • Member transportation to or from testing sites (unless the member meets requirements for ambulance services)

Antibody testing
Serologic testing for the presence of SARS-CoV-2 IgM/IgG antibodies is covered for FDA and Emergency Use Authorization tests (as described above) when ordered by a health care provider who is making an individualized clinical assessment of the patient in accordance with current standards of medical practice, including the Centers for Disease Control (CDC) and Massachusetts Department of Public Health (DPH) guidelines.

According to the CDC, serologic testing:

  • Should not be used to determine immune status in individuals
  • Should not be used to determine if someone can return to work.
  • Should not be used to group people together in settings such as schools, dormitories, and correctional facilities.
  • Can be offered as a method to support a diagnosis of acute COVID-19 illness for persons who present late. For persons who present 9-14 days after the onset of illness, serologic testing can be offered in addition to recommended direct detection methods, such as polymerase chain reaction*.
  • Should be offered as a method to help establish a diagnosis when patients present with late complications of COVID-19 illness, such as multisystem inflammatory syndrome in children

* Detection of specific antibody in serum, plasma, or whole blood that indicates new or recent infection provides presumptive laboratory evidence of COVID-19 illness, according to the Council of State and Territorial Epidemiologists (CSTE) interim case definition for COVID-19.

Serologic testing for the presence of antibodies is not covered

  • For general screening purposes such as:
    • return-to-work
    • clearance to travel
    • to attend school, day care or camp
  • For public health or surveillance purposes
  • For periodic or serial testing of asymptomatic individuals (examples include congregate housing, such as dormitories and residential facilities, and occupational safety)
  • For tests that have been denied FDA approval, an Emergency Use Authorization from the FDA, or laboratories that have not submitted an Emergency Use Authorization request within a reasonable timeframe
  • For member transportation to or from testing sites (unless the member meets requirements for ambulance services)
  • To screen for eligibility to donate plasma

Medicare HMO BlueSM and Medicare PPO BlueSM Members

In keeping with CMS guidance issued September 2, 2020 and for the duration of the COVID-19 public health emergency, Blue Cross will cover, without a healthcare professional’s order, the following:

  • The cost of one diagnostic test for COVID-19 and
  • The cost of one diagnostic test each for influenza virus or similar respiratory condition for Medicare members. These tests must be performed in conjunction with a COVID-19 test and needed to obtain a final COVID-19 diagnosis. Subsequent tests will require the order of an authorized health care professional.

Viral testing
The use of reverse transcription-polymerase chain reaction (RT-PCR) or antigen testing to detect the presence of SARS-CoV-2 for a diagnosis of COVID-19 infection is covered for FDA-approved tests when ordered by any healthcare professional authorized under state law.

Antibody testing
Serologic testing for the presence of antibodies for known or suspected current or prior COVID-19 infection is covered for FDA-approved tests when ordered by any healthcare professional authorized under state law.

Federal Employee Program

The Federal Employee Program (FEP) covers COVID-19 testing and antibody testing with no member cost share, regardless of provider status, including testing for:

  • travel purposes
  • asymptomatic members
  • pre-surgical testing for elective and non-elective procedures
  • return to work

Note: There are no limits on frequency of testing.

Resources

MPC_030620-1N-98-ART