At Home Covid Test
Group Health Plans Required to Cover the Cost of At-Home COVID-19 Tests
By: HUB’s EB Compliance Team
Beginning January 15, 2022, health insurance companies and group health plans are required to cover the cost of up to 8 over-the-counter, at-home COVID-19 tests per covered person per month, per recent FAQs. The new coverage requirement means that most health plan participants may buy an FDA-approved COVID-19 rapid test and either get it paid for up front by their health plan or get reimbursed by submitting a claim to their plan.
Insurance companies and health plans are required to cover at least 8 over-the-counter at-home tests for each covered individual, each month. For example, a family of four, all on the same plan, would be able to get up to 32 tests covered by their health plan each month. These over-the-counter 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 or coinsurance, prior authorization, or other medical management requirements. The 8-test safe harbor is intended to prevent enhancing existing supply chain issues with obtaining COVID-19 at-home tests.
However, this limit does not apply to tests (including rapid at-home tests) if they are ordered or administered by a health care provider. In other words, if the test is ordered or administered by a health care provider (even if it is an at-home test), it does not count against the 8-test limit.
As part of the requirement, the Administration is encouraging insurers and group health plans to set up programs that allow people to get the over-the-counter tests directly through in-network pharmacies and/or retailers at no cost. This could include direct-to-participant mailing of the tests. Insurers and plans would cover the costs upfront, eliminating the need for plan participants to submit a claim for reimbursement.
Out of Network Purchases
However, plans and health insurers cannot limit reimbursement to in-network pharmacies or providers. Instead, they are required to reimburse tests purchased by plan participants from out-of-network providers up to $12 for each test (or the cost of the test, if less than $12). 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. Plans are permitted to set a higher reimbursement maximum as well.
Note that this $12 limit appears to only apply if the group health plan or health insurer is providing tests both through its pharmacy network and a direct-to-consumer shipping program, without upfront cost to the participant. Plans also have to take reasonable steps to ensure participants have adequate access to tests under this direct coverage option. This means that if a group health plan or health insurer does not meet these requirements, it would have to fully reimburse the cost of out-of-network purchased tests. The “adequate access” requirement will be particularly difficult given current testing shortages, suggesting that, at least for a time, group health plans and health insurers may have fully reimburse the cost of any available test.
Notably, the guidance reiterates the government’s position that plans are not required to provide coverage of testing (including these at-home COVID-19 tests) that is for employment purposes. Therefore, employers that are working to comply with various mandates that require their employees to vaccinate or be tested do not need to use this new reimbursement requirement to satisfy those rules. For practical reasons, it may not make much sense to do so anyway since plan coverage would only be available to employees enrolled in the plan and existing federal mandates require that the COVID tests be proctored in some fashion (more detail on those is available under “Employment Law” here).
Additionally, plans and issuers are allowed to take reasonable steps to ensure that an OTC COVID-19 test is being obtained for personal use. However, the barriers must be minimal. For example, a simple attestation that the test was purchased for personal use, not employment purposes, and has not been (and will not be) reimbursed by another source, is allowed. Additionally, a reasonable proof of purchase requirement is also allowed (such as submitting a receipt). By contrast, extensive documentation or numerous steps are not reasonable.
As noted above, these new coverage requirements are effective Saturday, January 15, 2022 (although plans and health carriers can start earlier if they choose). The coverage is required as long as the Department of Health and Human Services says the public health emergency related to COVID-19 is in effect. This leaves plans and health coverage providers precious little time to implement claims processes to meet this new mandate. While it had been telegraphed by the President in an earlier Executive Order, the relative lack of detail then, and the additional details now, put plans and issuers in a difficult administrative spot.
Finally, the guidance notes that employers still have relief from the summary of benefits and coverage notice requirements when they ultimately are no longer required to cover these items or services. This is welcome news to employers, although it likely will not be relevant for a while.
The relevant federal departments have provided robust FAQs that provides additional information regarding this new coverage requirement.
Employers should promptly contact their carriers and health plan service providers (including pharmacy benefit managers, if applicable) to discuss the new mandate and ask if they are prepared for it. Employers will also need to get a sense of the process the carrier or service provider is using to meet this requirement so they can communicate it to their employees promptly. While the coverage is widely reported in the news, employees will likely have questions for employers, so a proactive communication strategy can help alleviate the burden of those questions.
NOTICE OF DISCLAIMER
Neither Hub International Limited nor any of its affiliated companies is a law or accounting firm, and therefore they cannot provide legal or tax advice. The information herein is provided for general information only, and is not intended to constitute legal or tax advice as to an organization’s or individual's specific circumstances. It is based on Hub International's understanding of the law as it exists on the date of this publication. Subsequent developments may result in this information becoming outdated or incorrect and Hub International does not have an obligation to update this information. You should consult an attorney, accountant, or other legal or tax professional regarding the application of the general information provided here