Important COVID-19 Testing Information

During this challenging and unprecedented time caused by the coronavirus outbreak, the Board of Trustees has decided that certain temporary changes to your health benefits are warranted for the protection and safety of all Plan participants. Further details are provided below but, effective for services and supplies rendered on or after March 18, 2020, and continuing until further notice, all patient cost sharing (i.e., co-pays, co-insurance and deductibles) will be temporarily waived for all testing for the detection and diagnosis of the COVID-19 virus and COVID-19 antibodies, however, there are various criteria that need to be met for this to take effect. Payment without cost sharing for COVID-19 testing by the Health Plan only applies if there is an order from the individual’s attending health care provider for a reason that is determined to be medically appropriate by the provider. If there is no order from your healthcare provider, the claims are processed with cost sharing, subject to your deductible, co-insurance and/or co-pay. Additionally, there are various scenarios that are not covered at all by the Health Plan and any testing for the reasons stated below will be denied:

  • Testing for work.
  • Testing for school.
  • Testing for public health surveillance or for any other purpose not primarily intended for the individualized diagnosis or treatment of COVID-19 or another health condition.

If you have an order from your attending health care provider, please submit a copy to the Health Plan via email to hpclaims@dgaplans.org, fax it to (323) 782-9287 or mail it to 5055 Wilshire Blvd, Suite 600, Los Angeles, CA 90036.

The Plan’s waiver of cost sharing will apply to testing-related office visits, telemedicine visits, urgent care centers, and hospital emergency room visits for the purpose of COVID-19 testing. There are a couple other important things to keep in mind about the rules regarding cost-sharing:

  • The waiver of cost sharing only applies to items and services furnished to an individual during visits that result in an order for, or administration of, a COVID-19 diagnostic test, but only to the extent that the items or services relate to testing for the virus or the evaluation of the individual to determine if he or she needs testing.
  • The waiver of cost sharing does not apply to medical treatments following a diagnosis of COVID-19. Those treatments are subject to all other Health Plan rules.

These rules are intended to comply with, and will be administered and applied in accordance with, the requirements of the new Families First Coronavirus Response Act and the Coronavirus Aid, Relief, and Economic Security Act.

Already Been Tested?

Select the applicable scenario below for information on Health Plan coverage of your COVID-19 test.

I received a test (for a reason other than work, school, etc.) without first obtaining a medical order from my healthcare provider.

Payment without cost sharing for COVID-19 testing by the Health Plan only applies if there is an order from the individual’s attending health care provider for a reason that is determined to be medically appropriate by the provider. The provider’s orders are required to confirm the test was ordered by the attending healthcare provider following an individualized assessment. If there is no order from your healthcare provider, the claims are processed with cost sharing, subject to your deductible and co-insurance.

I received a test after finding a free testing location on a website, stating testing is free and that insurance may not bill you. I did not have a medical order from my healthcare provider.

The statement posted on the cities’ website is partially true, however, it unfortunately fails to indicate that certain criteria must be met in order for COVID-19 testing to be eligible for coverage under the Health Plan without cost sharing. Payment without cost sharing for COVID-19 testing by the Health Plan only applies if there is an order from the individual’s attending health care provider for a reason that is determined to be medically appropriate by the provider. The provider’s orders are required to confirm the test was ordered by the attending healthcare provider following an individualized assessment. If there is no order from your healthcare provider, then the claims are processed with cost sharing, subject to your deductible and co-insurance.

I received a drive-through test (or any method that did not include an actual office visit) but a separate office visit has been billed with the test.

Payment without cost sharing for COVID-19 testing by the Health Plan only applies if there is an order from the individual’s attending health care provider for a reason that is determined to be medically appropriate by the provider. The provider’s orders are required to confirm the test was ordered by the attending healthcare provider following an individualized assessment. If there is no order from your healthcare provider, then the claims are processed with cost sharing, subject to your deductible and co-insurance. Additionally, labs should not be billing for office visits if no actual office visit with an attending healthcare provider occurred (either in person or via teleconference). Accordingly, any office visit charges that are billed by a lab will be denied as not being within the scope of the provider’s license. We recommend that you contact your provider to dispute this charge as an office visit does not appear to have occurred.

I received a positive test result and was re-tested. Due to the exposure, my family received tests. We did not first obtain medical orders from our healthcare provider.

Payment without cost sharing for COVID-19 testing by the Health Plan only applies if there is an order from the individual’s attending health care provider for a reason that is determined to be medically appropriate by the provider. The provider’s orders are required to confirm the test was ordered by the attending healthcare provider following an individualized assessment. If there is no order from your healthcare provider, then the claims are processed with cost sharing, subject to your deductible and co-insurance.