Oscar told members of its health insurance plans in an email last week that it may not cover costs associated with COVID-19 antibody testing. It had cited those costs in a May filing as a reason it would need to raise premiums in 2021.
The email informed members that the insurer would cover the tests, which can show that a person has been exposed to COVID-19, only for specific reasons.
"We cover medically necessary antibody testing as required by the CARES Act, but only when it's being used to diagnose COVID-19 or determine a treatment plan, and the antibody test is provided in line with CDC recommendations," the insurer wrote in the email, which members received Tuesday morning.
An Oscar spokeswoman told Crain's that the insurer's application to New York to increase its premiums would be revised, and the mention of coverage of antibody testing driving up costs was submitted to the state in early May.
"Every year rate setting is an iterative process, and our team is working with state regulators to revise our submission, taking into account additional information that has become available since the initial filing," she said.
The email was little consolation to Oscar member Bryan Byczek. The 40-year-old graphic designer from Brooklyn went to a MedRite Urgent Care clinic last week to receive an antibody test. He had used the state's website to find a testing location and assumed the cost would be covered. Now he's waiting for a bill to arrive.
"Receiving that letter so late in the game—months and months into it—is disappointing," Byczek said. "I personally can afford to cover the test, but I know there are others that can't."
Oscar said it would pay for the test if it were being used to help identify multisystem inflammatory syndrome, a complication that has been identified in children who previously had COVID-19 or were exposed to someone with the disease, and other such cases.
Oscar will not cover the test for individuals interested in finding out if they have antibodies for a sense of security before they see family members, as was the case with Byczek.
"Having antibodies may not mean that you're immune to the virus, so antibody testing can't tell you if you're protected from repeat infection," Oscar wrote. "The CDC also doesn't recommend the use of antibody testing to determine if you can return to work."
It told members they would have to pay for the test out of pocket, and the cost of the test won't apply to their deductible.
Guidance from New York's Department of Financial Services has noted the federal CARES Act requires insurers to cover antibody tests without asking members to pay copays, coinsurance or deductible payments when a health care provider determines the test is medically appropriate. The Oscar spokeswoman said Oscar covers medically necessary antibody testing that meet its clinical criteria.
The Department of Financial Services said it doesn't comment on pending rate requests.
Oscar is seeking to raise premiums by an average of 19.1% in 2021. Byczek's plan will cost 20% more next year, or $680 a month. The state must approve or adjust Oscar's request, which was the highest on average statewide, before it goes into effect.
Elisabeth Benjamin, vice president of health initiatives at the Community Service Society, said Oscar shouldn't be able to raise its prices to account for a COVID-19 treatment or vaccine that may not materialize. She noted that insurers have saved money as their members have skipped routine care during the pandemic. It also should be covering antibody testing under the state's guidance to insurers, she said, noting that NYC Health + Hospitals is offering free antibody testing.
"Why aren't they driving a good bargain on antibody testing?" Benjamin asked. "The whole point of the individual market is they will negotiate a better rate than an individual could on their own."
"Oscar tells members it won't cover most antibody tests" originally appeared in Crain's New York Business.