Insurers will bemaking judgment calls — likely on a case-by-case basis — about howthey will handle cost-sharing for screening tests under the newTrump administration guidance.

In advance of an upcoming road trip with her elderly parents,Wendy Epstein's physician agreed it would be "prudent" for her andher kids to get tested for COVID-19.

Seeing the tests as a "medical need," the doctor said insurancewould likely pay for them, with no out-of-pocket cost to Epstein.But her children's pediatrician said the test would count as ascreening test — since the children were not showing symptoms — andshe would probably have to foot the bill herself.

Related: Will insurance cover it? COVID-19 testing confusioncontinues

It made no sense. "That's two different responses for the exactsame scenario," said Epstein, a health law professor at DePaulUniversity in Chicago, who deferred the tests as she clarified theoptions.

Early on in the coronavirus pandemic — when scarce COVID testingwas limited to those with serious symptoms or serious exposure —the government and insurers vowed that tests would be dispensed forfree (with no copays, deductibles or other out-of-pocket expense)to ensure that those in need had ready access.

Now, those promises are being rolled back in ways that arecreating turmoil for consumers, even as testing has become moreplentiful and more people — like Epstein — are being advised to getthem.

Late last month, the Trump administration issued guidancesaying insurers had to waive patient costs only for "medicallyappropriate" tests "primarily intended for individualized diagnosisor treatment of COVID-19." It made clear that insurers do not haveto fully waive cost sharing for screening tests, even when requiredfor employees returning to work or for assisting in public healthsurveillance efforts.

Left unclear are situations like that faced by Epstein — andothers who seek a test to clear a child for summer camp or daycare. Public health officials have been unanimous in the opinionthat widespread, readily available testing is crucial for gettingbusinesses and schools open again, and society back on itsfeet.

But who should bear the costs of that testing — or a share ofthem — is an unresolved question.

Who pays when all employees are required to have a negativeCOVID test in order to return to work? Or if a factory testsworkers every two weeks? Or just because someone wants to know fortheir own peace of mind?

The questions may be compounded in some cities and states wheretests are widely available at clinics or drive-thru centers. In NewYork, CityMD clinics bill insurers $300 for the service, accordingto an explanation-of-benefits document given to KHN by a patient.The related charge from the lab that processed the test, accordingto the same patient's insurance statement, was $55. Most patientsdon't have to pay a share of those amounts.

The clinic has a partnership with the city allowing anyone whowants a test for the virus to get one. Still, no test is trulyfree, as labs bill insurers or submit for reimbursement fromgovernment programs.

Until a recent spike in virus cases created long delays in manyareas, some other regions also took atest-everyone-who-wants-a-test approach. While that is one way toget a picture of where the virus is spreading, it can also become acash cow providing income to clinics and labs, as residents seekmultiple "free" tests after each potential exposure.

In an email, a spokesperson for CityMD would not say how muchthe clinic is reimbursed for testing. The clinics do not bill forlab testing, she wrote, referring questions about those costs tothe laboratories that process them.

Insurers will be making judgment calls — likely on acase-by-case basis — about how they will handle cost-sharing forscreening tests under the new Trump administration guidance.

What is clear: Insurers have argued against requirements thatthey waive all cost-sharing for workplace COVID testing, notingthey don't do that for other screening efforts, such asdrug-testing programs. For now, insurers will "continue to pay fortests recommended by a doctor," Kristine Grow, spokesperson forAHIP, an industry group, wrote in an email to KHN.

But AHIP also sent a clear signal that it would not embracecost-sharing waivers for workplace or public health screeningefforts. Earlier this month, the organization lobbied federallawmakers to include funding in the next stimulus package for public healthsurveillance and workplace testing programs — a cost estimatedbetween $6 billion and $25 billion annually in an earlier studycommissioned by the group.

The evolving rules for free testing

The coronavirus relief legislation passed by Congress in March,and April guidancefrom the Trump administration implementing it, agreed thatpatients should not be burdened with payments for COVID testing andtreatment that is "medically appropriate."

But as the pandemic has evolved and grown, the definition ofthat term has both broadened and become fuzzier.

The Centers for Disease Control and Prevention says testing isappropriate for people who fall into five broad categories,including those with suspected exposure and those required to betested for "purposes of public health surveillance," which itdefines as checking for disease hot spots or trends.

"There's definitely a disconnect between what public healthexperts are recommending for testing and how it's going to be paidfor," said Sabrina Corlette, co-director of the Center on HealthInsurance Reforms at Georgetown University.

And tension is mounting among insurers, employers and consumersover who should pay. While insurers say employers should cover thecost for back-to-work testing, many employers are strugglingfinancially and may not be able to do so. At the same time,workers, especially those in lower-wage jobs, also cannot affordout-of-pocket costs for testing, particularly if it is requiredregularly.

Among those waiting to hear if their insurance will cover thetest is Enna Allen of Glencoe, Illinois, who urged her au pair toget a test after the young woman traveled to New Orleans. She hadbeen on a plane, after all, and New Orleans has its share of COVIDcases.

"I wanted her to have a test before she returned to work with mykids," said Allen.

As Allen called around to find a testing site, she explained thetest was needed for employment — for someone with no symptoms.After some effort, she found a clinic that, for $275, offered a15-minute rapid test and said it would accept her au pair'sinsurance.

"I'm assuming they [the insurer] will cover it unless I get abill weeks from now," said Allen, who said she would pay the billfor her employee if that happens.

There is also a great gray area in deciding who should qualifyfor free testing after "suspected" exposure. What is suspectedexposure? Sharing a small office with an infected co-worker?Participating in a protest? Or simply living in or visiting the SunBelt, where community spread is accelerating?

"If the au pair went to a clinic and said she was just in NewOrleans, and the doctor said that's enough of a risk to order atest, even though she doesn't have symptoms, my read of theguidance is the health plan has to cover it 100%," saidCorlette.

Yet a child who's mainly been sheltering at home who needs atest before being admitted to summer camp probably would not meetthe definition.

"That's a different story because it's harder to argue there'sbeen exposure or potential exposure," said Corlette. "At the end ofthe day, there's many ways to interpret the guidance."

Congressional Democrats have accused the Trump administrationin its new guidance of "giving insurance companies loopholesinstead of getting people the free testing they need."

Insurers, patients and politicians have locked horns before whenscreening tests were billed differently than those same tests fordiagnostic purposes, since the boundary is often unclear. Under theAffordable Care Act, for example, colonoscopy screening for canceris "free," meaning no patient copayment. But if a polyp is found,doctors sometimes code the procedure as a diagnostic test, whichcan lead to hundreds or even thousands of dollars incopayments.

While vital, testing is costly — or can be. Medicare reimbursesup to $100 for the COVID test. On top of that, there may also becosts associated with the office or clinic visit. And the price iswidely variable in the private market, according to a report out last week by KFF, the Kaiser Family Foundation.Prices ranged from $20 to $850 for a single test. (KHN is aneditorially independent program of the foundation.)

Media reports have shown tests average $100, but some labs billinsurers for thousands of dollars for each one.

Without a copay, many patients never learn how much their testsactually cost their insurers, which could lead to overuse.

Also, when patients are entirely shielded from the cost, testmakers, labs and medical providers are more likely to seek priceincreases, said Heather Meade, a principal at Washington CouncilErnst & Young.

In the end, consumers may still feel a resulting pinch in theform of higher premiums.

Wondering about the sharply different views of her doctors onwhether her insurance would fully cover the cost, law professorEpstein called her insurer, which assured her the tests would becovered 100% at in-network providers with no copay or deductible,as long as they were coded correctly. The family will be testedsoon, and it appears she's dodged a financial bullet. But Epsteincautioned in an email: "It's unclear to me how many insurers willmaintain this policy."

KHN (Kaiser HealthNews) is a nonprofit news service covering health issues. It is aneditorially independent program of KFF (Kaiser Family Foundation),which is not affiliated with Kaiser Permanente.

Read more: 

• COVID-19 testing may play a central role in manyemployers' return-to-work strategy
• Short-term health insurers expanding COVID-19testing coverage
• Some 'excepted benefits' policies might coverCOVID-19 testing