COVID-19 Testing and Cost Share Guidance

For dates of service on or after May 12, 2023, UnitedHealthcare will not cover OTC COVID-19 tests unless mandated by state regulatory requirements. Members may use their account plans, such as Health Savings Accounts (HSA) and Flexible Spending Accounts (FSA) to purchase OTC tests. Individual plans may vary. Refer to plan benefits for more detail. 

For dates of service on or after May 12, 2023, UnitedHealthcare Medicare Advantage plans will not cover OTC COVID-19 tests under the plan’s medical benefits. UnitedHealthcare Medicare Advantage plans with an OTC benefit will continue to offer at-home test kits through the OTC benefit.

For dates of service on or after May 12, 2023, UnitedHealthcare will not cover OTC COVID-19 tests unless mandated by state regulatory requirements. State requirements may vary. Please refer to your state’s COVID-19-specific website for more information. 

UnitedHealthcare will cover medically appropriate COVID-19 testing during the national public health emergency period (currently scheduled to end May 11, 2023), at no cost share, when ordered or reviewed by a physician or appropriately licensed health care professional* to either:

1. diagnose if the virus is present due to symptoms or potential exposure, or
2. help in the treatment of the virus for a person

Additional Information

• This coverage applies to in-network and out-of-of-network tests for Medicare Advantage, Individual and Family Plans and Individual and Group Market health plans..
  • For individuals enrolled in UnitedHealthcare Community Plans, state variations and regulations may apply during this time.
• Tests must be FDA-authorized to be covered without cost sharing (copayment, coinsurance or deductible). 
  • FDA-authorized tests include tests approved for patient use through pre-market approval or emergency use pathways, and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval.
• We continue to monitor regulatory developments during emergency periods.

Reimbursement

• We will reimburse COVID-19 testing in accordance with applicable law, including the CARES Act and UnitedHealthcare reimbursement requirements. State variations and regulations may apply during this time. 
• Please do not collect upfront payment from the member.
• If members receive medical services or advice for other conditions at the same time as receiving a COVID test, then cost sharing will be adjudicated in accordance with the member’s health plan and they will be responsible for any copay, coinsurance, deductible or other out-of-network costs.   

Surveillance Testing

UnitedHealthcare health plans generally do not cover COVID-19 surveillance testing, which is testing used for public health or social purposes such as employment (return to workplace), education, travel or entertainment. These tests are only covered when required by applicable law and adjudicated in accordance with the member’s benefit plan.

• Exception for Administrative Services Only plans:  Effective Jan. 1, 2022, Administrative Services Only (ASO) plans may elect to cover surveillance testing claims administered by a health care provider under the medical benefit plan. ASO plans are health plans through which UnitedHealthcare only adjudicates claims on behalf of the employer. They are sometimes referred to as self-funded plans. Members are responsible for checking with their employer to see if they have elected to cover surveillance testing in 2022.

Variant Testing

UnitedHealthcare health plans do not cover variant testing to detect mutations for reporting purposes, including testing authorized and/or approved (done) by the FDA to classify variants. Although the AMA has released CPT code 87913 for detection of mutations (reporting-related testing), any claim submitted to UnitedHealthcare with this code will be denied. 

Over-the-Counter Testing

If a health care professional provides a prescription or order for the over-the-counter COVID-19 test as part of clinical care, the member may submit a claim for reimbursement with both the prescription and detailed receipt to UnitedHealthcare. State variations and regulations may apply. Please see the “Over-the-Counter At-Home Test Guidance” section below for details about coverage and reimbursement for over-the-counter tests purchased without a prescription.

*Licensure requirements vary by state. In some states, a pharmacist or other health care professional, such as a nurse practitioner, may have the appropriate licensure to order a test. Please refer to state-specific licensure requirements for appropriate guidance.

Date Reference Guide: Keep track of which temporary measures are expiring and which are being extended with our Summary of COVID-19 Temporary Program Provisions.

A virus detection diagnostic (molecular or antigen) test determines if a person is currently infected with COVID-19, while an antibody (serology) test may determine if a person has been exposed to COVID-19. 

Testing coverage may vary by health plan. Please review each section below for details. Dates are subject to change based on the national public health emergency period. 

• Virus Detection Diagnostic (Molecular or Antigen) and Antibody Testing: UnitedHealthcare will cover medically appropriate COVID-19 testing for the following health plans at no cost share, when ordered or reviewed by a physician or appropriately licensed health care professional* to either:
  1) diagnose if the virus is present due to symptoms or potential exposure, or 2) help in the treatment of the virus for a person.
  • Medicare Advantage
    Waiver of cost share is effective from Feb. 4, 2020, through the end of the national public health emergency on May 11, 2023, for in-network and out-of-network tests.
    
  • Individual and Group Market health plans
    Waiver of cost share is effective from Feb. 4, 2020, through the end of the national public health emergency on May 11, 2023, for in-network and out-of-network tests.
    
  • Medicaid
    Waiver of cost share is subject to state regulations. 

UnitedHealthcare health plans do not cover COVID-19 surveillance testing, which is testing used for public health or social purposes such as employment (return to workplace), education, travel or entertainment. These tests are only covered when required by applicable law and adjudicated in accordance with the member’s benefit plan.

And, like other over-the-counter health products, COVID-19 tests purchased over-the-counter – without a prescription or doctor’s involvement through a clinical lab – are generally not covered by UnitedHealthcare health plans. Members will be responsible for any cost, and they may use a health savings account (HSA), flexible spending account (FSA) or health reimbursement account (HRA). If a health care professional provides a prescription or order for the over-the-counter COVID-19 test as part of clinical care, the member may submit a claim for reimbursement with both the prescription and detailed receipt to UnitedHealthcare. State variations and regulations may apply.

Tests must be FDA authorized to be covered without cost sharing (copayment, coinsurance or deductible). FDA-authorized tests include tests approved for patient use through pre-market approval or emergency use pathways, and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval.

Members should work with their provider to order a test. Additional member guidance on testing can be found here.

Please do not collect upfront payment from the member. Benefits will be otherwise adjudicated in accordance with the member’s health plan. We will reimburse COVID-19 testing in accordance with applicable law, including the CARES Act and UnitedHealthcare’s reimbursement requirements. State variations and regulations may apply during this time. 

Temporary Program Provisions Reference Guide: Keep track of which temporary measures are expiring and which are being extended with our summary of COVID-19 temporary program provisions

• Rapid Point of Care Testing: UnitedHealthcare will cover FDA-authorized rapid point of care virus/antigen detection and antibody testing.
  
  
• COVID-19 Testing-Related Services: UnitedHealthcare is also waiving cost sharing for COVID-19 testing-related services received in-person or via telehealth for the following health plans: 
  
  • Medicare Advantage
    Waiver of cost share is effective from Feb. 4, 2020, through the end of the national public health emergency on May 11, 2023, for in-network and out-of-network testing-related services.
    
  • Individual and Group Market health plans
    Waiver of cost share is effective from Feb. 4, 2020, through the end of the national public health emergency on May 11, 2023, for in-network and out-of-network testing-related services.
    
  • Medicaid
    Waiver of cost share is subject to state regulations.
     
• COVID-19 Treatment: More information is available on the COVID-19 treatment page.
  
• Telehealth Services: More information is available on the COVID-19 telehealth page.

*Licensure requirements vary by state. In some states, a pharmacist or other health care professional, such as a nurse practitioner, may have the appropriate licensure to order a test. Please refer to state-specific licensure requirements for appropriate guidance.

An antibody test may determine if a person has been exposed to COVID-19, while a COVID-19 diagnostic test determines if a person is currently infected. FDA authorized tests include tests approved for patient use through pre-market approval or emergency use pathways, and tests that are developed and administered in accordance with FDA specifications or through state regulatory approval. According to the FDA, an antibody test should not be used to diagnose a current infection. Virus detection should be used to diagnose a current infection. UnitedHealthcare strongly supports the need for reliable testing and encourages health care providers to use reliable FDA-authorized tests.

Test Registration Requested

UnitedHealthcare is requesting all physicians and health care professionals who perform and bill for COVID-19 antibody tests to register the test(s) that will be used for our members. This includes both hospital-affiliated and freestanding laboratories, as well as physician practices with in-house laboratories. The registration takes just a few minutes to complete. You’ll need to complete it for each specific test you offer. (For example, if you have two different tests that are offered to physicians/patients, you’ll need to complete the registration twice.) If you change the test(s) you use in the coming months, you’ll need to complete the survey again.

Please complete the COVID-19 Antibody Test Registration as soon as possible. To complete the test registration, you’ll need:

• The laboratory tax ID number (TIN)
• The type of antibody test rendered

UnitedHealthcare will use the registration information to assist providers in choosing tests that are FDA authorized and to better understand the clinical reliability of the tests being used.

UnitedHealthcare is following the Centers for Disease Control and Prevention (CDC) guidelines, which recommend that a physician or appropriately licensed health care professional* order the test. FDA-approved or authorized tests are sent to an approved laboratory that can properly test for the presence of COVID-19.

COVID-19 tests can be ordered through a public health facility, commercial laboratory (e.g., LabCorp and Quest Diagnostics) or hospital. The commercial laboratory testing through LabCorp and Quest Diagnostics became available March 11, 2020. Additional laboratories — including local hospital systems — are also beginning to test.

If a health care professional determines their patient needs a COVID-19 test, but is not able to conduct the test themselves, then health care professionals should work with their local and state health department or an affiliated hospital to determine where their patients can get tested in their community. Depending on the patient’s identification, acuity and location, they may get any one of the approved tests. Care providers are encouraged to call ahead and work with their patients to take proper isolation precautions when referring them for testing.

*Licensure requirements vary by state. In some states, a pharmacist or other health care professional, such as a nurse practitioner, may have the appropriate licensure to order a test. Please refer to state-specific licensure requirements for appropriate guidance.

Care providers should follow the guidance from commercial laboratories to help ensure that they properly collect and ship the COVID-19 specimens. For more information, review the CDC’s guidelines for COVID-19 specimen collection. Or, visit  labcorp.com and/or questdiagnostics.com.

UnitedHealth Group released a study that shows self-administered tests are 90% effective and significantly reduce the risk of infection for care providers when collecting the tests. Currently, self-administered tests must be:

• Ordered by a physician or health care provider (MD, DO, PA or NP), so clinics can register the test and help ensure chain of custody for the results
  
• Conducted in the physical presence of a health care professional to help ensure the collection is done the right way (e.g., the patient put the nasal swab far enough into their nose to collect an appropriate sample – can’t just touch the nose)
  
• Coordinated through local and state health departments for laboratory testing or use COVID-19 virus detection testing labs authorized by the FDA under the emergency use authorization act
  

Member cost share

We will waive cost share for specimen collection when billed without an E&M code and with one of the appropriate ICD-10 diagnosis codes: Z03.818, Z20.828 (effective Feb. 4, 2021) or Z20.822 (effective Jan. 1, 2021).

• For Medicare Advantage health plans, use CPT^® code 99001 or 99211
• For Individual and Group Market health plans, you can use CPT codes 99000 and/or 99001

We will not reimburse for specimen collection if billed with separate E&M codes. If an E&M service is not provided, 99001 can be used for pop-up labs or specimen collection offsite.