Group Health Plans Must Cover At-Home COVID-19 Tests Without Cost-Sharing
Beginning January 15, 2022, individuals with employer-sponsored health insurance who purchase an at-home over-the-counter (OTC) COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those tests covered by their health insurance carrier or group health plan, according to guidance issued by the Department of Labor (DOL), the Department of Health and Human Services (HHS), and the Treasury Department (Treasury).
According to the guidance, issued as frequently asked questions (FAQs), health insurance carriers and group health plans are required to cover eight free OTC COVID-19 tests per covered individual per month. This means that a family of four, all covered under the same health plan, would be able to get up to 32 tests covered by their health plan per month. In addition, there is no limit on the number of tests that are covered if ordered or administered by a health care provider following an individualized clinical assessment, or for those who may need the tests due to underlying medical conditions.
The OTC COVID-19 test purchases will be covered without the need for a health care provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments, coinsurance, prior authorization, or other medical management requirements.
As part of this new program, DOL, HHS, and Treasury are incentivizing health insurance carriers and group health plans to set up arrangements that allow people to get the OTC COVID-19 tests directly through networks of preferred pharmacies, retailers, or other entities with no out-of-pocket costs. Insurers and health plans would cover the cost of the tests up front, eliminating the need for consumers to submit a claim for reimbursement. If a health insurance carrier or group health plan has not set up a network of preferred pharmacies or retailers from which individuals can obtain the tests with no out-of-pocket costs, individuals should pay for the tests up front, save the receipt and file a claim for reimbursement with their health insurance carrier or group health plan.
Health insurance carriers and group health plans are required to cover the OTC COVID-19 tests purchased on or after January 15, 2022. Health insurance carriers and group health plans may, but are not required by federal law, to provide coverage for any tests purchased before January 15, 2022.