Q: When does the requirement for our health plan to cover Over-the-Counter “OTC” COVID-19 tests go into effect and how will it work?
A: On January 10th, the Department of Labor issued guidance on OTC COVID-19 tests in the document FAQS About Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation. The home testing coverage requirement is effective January 15, 2022.
Health Plans will need to follow the following criteria:
- Plans and issuers must cover the costs of COVID-19 tests during the COVID-19 public health emergency without imposing any cost-sharing requirements, prior authorization, or other medical management requirements. As of January 15, 2022, OTC home tests must be covered without the involvement of a physician. This is for all FDA-authorized home tests purchased through pharmacies, retail stores, or online retailers.
- Health plans must allow a minimum of 8 tests per month for each individual covered under the plan. If more than one test is purchased or ordered at a time, such as a package with two tests, then this would count as two tests for the month.
- Health Plans are encouraged to arrange for direct coverage through a preferred network. If the plan has set up direct coverage through a preferred provider network, the provider would submit the claim directly to the plan and the plan will pay the total cost of the test. If the member does not use a participating provider, the plan is permitted to limit the reimbursement to $12 per test. If the package purchased includes two tests, then the plan would reimburse the member $24.
- If the plan does not provide coverage through a network of preferred stores or online retailers, the member will be reimbursed at 100% of the cost of the test.
This FAQ does not modify previous guidance addressing coverage for purposes not primarily intended for individualized diagnosis or treatment of COVID-19, including the guidance that states that plans and issuers are not required to provide coverage of testing (including an OTC COVID-19 test) that is for employment purposes.
Plans and insurers are in the process of determining if they will use a preferred network or require the individual to submit a claim for reimbursement. Members should save their receipts for home testing kits purchased until the insurer or third-party administrator has updated their benefit payment system.
The carriers/administrators will contact employer groups and Liberty Insurance when they finalize their process for managing the claims for the home OTC test.
Employers are encouraged to review the DOL FAQ for OTC Testing as well as the CMS FAQ – How to get your At-Home Over-The-Counter COVID-19 Test for Free to better understand the plan requirements and respond to member questions.