Mandate Requires Coverage of At-Home COVID-19 Testing by Insurers, Group Health Plans

Over-the-counter (OTC), at-home COVID-19 tests will be covered by insurance companies and group health plans beginning January 15, 2022, under the Biden-Harris Administration.

According to a Centers for Medicare & Medicaid Services (CMS) press release, most consumers will be able to buy a COVID-19 test either at a pharmacy, store, or online and it will be paid for up front or reimbursed by submitting a claim to their health care plan.

“Testing is critically important to help reduce the spread of COVID-19, as well as to quickly diagnose COVID-19 so that it can be effectively treated,” said CMS Administrator Chiquita Brooks-LaSure.

Covered individuals will be eligible for 8 free OTC, at-home tests per month. For individuals who need tests due to underlying medical conditions or if a health care provider orders or administers a test following a clinical assessment, there is no limit on the number of tests, according to CMS.

CMS noted in its press release that per this requirement, insurers are incentivized to cover these costs up front so an order from an individual’s health care provider will not be necessary in order to access the free tests.

Furthermore, other medical management requirements, deductibles, co-payments or coinsurance, or prior authorization will not be required for these tests.

“When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12),” stated CMS in the press release. “For example, if an individual has a plan that offers direct coverage through their preferred pharmacy, but that individual instead purchases tests through an online retailer, the plan is still required to reimburse them up to $12 per individual test.”

In addition, the US Department of Health and Human Services (HHS) has provided upwards of 50 million tests at no cost to health clinics and centers across the country. HHS and the Federal Emergency Management Agency have also created more than 10,000 free community-based testing states nationwide in an effort to provide increased access to in-need and rural populations.

Reference:
Centers for Medicare & Medicaid Services. Biden-Harris administration requires insurance companies and group health plans to cover the cost of at-home COVID-19 tests, increasing access to free tests. January 10, 2022. Accessed January 11, 2022.
https://www.cms.gov/newsroom/press-releases/biden-harris-administration-requires-insurance-companies-and-group-health-plans-cover-cost-home