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.
To read the FAQs, click here.
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