On Monday January 10, the Departments of Labor, Health and Human Services (HHS), and the Treasury jointly released a set of Frequently Ask Questions (FAQs) implementing President Biden’s directive that health insurance plans cover at-home COVID-19 tests. Beginning Saturday, January 15th, private insurers and group health plans will be required to cover the cost of FDA-approved over-the-counter COVID-19 diagnostic testing kits for all enrolled individuals.
The FAQ covers:
What Tests are Covered?
- The policy covers any at-home over-the-counter COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration (FDA), whether purchased online or in-person.
- Insurers are required to cover (either direct coverage or reimbursement) up to 8 tests per enrolled person per month (i.e. a family of four are covered for 32 tests per month).
- The test limit applies to each individual test, regardless of how they are packaged (e.g., two tests are often packaged in one box).
- Insurers are not required to cover tests used for employment purposes.
- Insurers generally must cover unlimited tests, including at-home diagnostic tests, ordered or administered by a health care provider.
How will Reimbursement Work?
- Tests must either be free directly to consumers at the point of sale, or insurers must reimburse beneficiaries the full cost of the test upon their submission of a valid receipt (purchased on or after January 15, 2022).
- Note: Some states may have existing requirements related to insurer coverage of at-home over-the-counter COVID-19 tests that may apply.
- Insurers must accept all reimbursement claims submitted with a valid receipt(s) and must not unduly delay reimbursement.
- CMS strongly encourages insurers to develop a network of convenient locations (e.g., pharmacies, stores, online retailers, etc.) for beneficiaries to obtain tests with no upfront cost at the direct point of sale. If the insurer has set up a network of preferred retailers, beneficiaries who purchase a test outside that network are still entitled to reimbursement from the insurer of up to $12 per individual test upon submission of a valid receipt.
- Note: CMS describes this policy as an incentive for insurers to establish networks of “no upfront cost” options by permitting them to limit reimbursement on out-of-network tests to $12 (if no network is established, insurers are required to reimburse the full cost of the test)
Authority
- Regarding its authority to issue the guidance, DOL invoked section 6001 of the Families First Coronavirus Relief Act, which generally requires group plans and issuers to cover services related to COVID-19 testing or diagnosis, which was then amended by the CARES Act to include a broader range of diagnostic items and services.
The policy does not cover public insurance programs such as Medicare (including Medicare Advantage), Medicaid, and Tricare.
For more information, the DOL’s FAQ can be found here.