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New FAQs Provide Guidance Regarding Coverage of Diagnostic COVID-19 Testing
By Burnham Compliance
01.13.22

On January 10, 2022, the Departments of Labor, Health and Human Services, and the Treasury issued frequently asked questions (FAQ) guidance regarding the requirements for group health plans and health insurance issuers to cover at-home over-the-counter (OTC) COVID-19 diagnostic tests during the COVID-19 health emergency period. Specifically, plans and issuers must cover the costs of up to eight OTC tests per covered individual per month without imposing any cost-sharing requirements, prior authorization, or other medical management requirements.

Under guidance issued in June 2020, at-home COVID-19 tests had to be covered only if they were ordered by a health care provider who determined that the test was medically appropriate for the individual. At that time, the Food and Drug Administration (FDA) had not yet authorized any at-home COVID-19 diagnostic tests. Since then, several types of OTC at-home tests have been approved.

As of January 15, 2022, the cost of these tests must be covered even if they are obtained without the involvement of a health care provider. In addition to setting a limit on the number or frequency of OTC COVID-19 tests that are covered to no less than eight tests per month or 30-day period, plans and insurance issuers may place other limits on coverage, such as:

  • Not requiring tests to be covered if they are not for individualized diagnosis (such as tests for employment purposes).
  • Requiring individuals to purchase a test and submit a claim for reimbursement, rather than providing direct coverage to sellers.
  • Providing direct coverage though pharmacy networks or direct-to consumer shipping programs and limiting reimbursements to other sources (the actual cost of the test, or $12, whichever is lower).
  • Taking steps to prevent, detect and address fraud and abuse.

ADDITIONAL INFORMATION

To read the FAQs, click here.

Please contact your Burnham Benefits Consultant or Burnham Benefits at 949‐833‐2983 or inquiries@burnhambenefits.com.


Burnham Benefits does not engage in the practice of law and this publication should not be construed as the providing of legal advice or a legal opinion of any kind. The consulting advice we provide is intended solely to assist in assessing its compliance with the Patient Protection and Affordable Care Act and other applicable federal and state law requirements, and is based on Burnham Benefit’s interpretation of federal guidance in effect as of the date of this publication. To the best of our knowledge, the information provided herein, and assumptions relied on, are reasonable and accurate as of the date of this publication. Furthermore, to ensure compliance with IRS Circular 230, any tax advice contained in this publication is not intended to be used, and cannot be used, for purposes of (i) avoiding penalties imposed under the United States Internal Revenue Code or (ii) promoting, marketing or recommending to another person any tax-related matter.