Advocacy News – January 13, 2022
Starting January 15, most Americans with health insurance will be able to secure an at-home over-the-counter (OTC) COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no cost. The cost of a test at pharmacies and retailers will either be free of charge, if your health plan provides for direct coverage, or reimbursed by your insurer (if you are charged for a test).
The details of how this will work was outlined in new guidance released by the federal government Monday. Under the guidance, insurers are incentivized to use their bargaining power with in-network pharmacies and other retailers to ensure enrollees can obtain at-home tests without cost sharing (i.e., for free) at the pharmacy or retail counter. The goal is to streamline access to rapid tests.
Key components:
- The guidance only applies to individuals with private health insurance, including individuals who are covered by individual insurance or group health plans (plans offered by employers). It does not apply to individuals who are uninsured. For the uninsured, at-home COVID-19 tests continue to be available through health centers, rural clinics and other key community sites, including federally supported free testing sites.
- The guidance allows individuals to secure eight tests per person per 30-day period (i.e., 32 tests per 30 days for a family of four).
- In general, insurers and plans cannot limit coverage or reimbursement to tests purchased at in-network pharmacies and other retailers, meaning individuals can obtain a test and seek reimbursement no matter where they purchased their test from—whether at an in-network pharmacy or through an out-of-network provider or an online provider.
- Insurers may limit reimbursement for OTC COVID-19 tests from nonpreferred pharmacies or other retailers to no less than the actual price, or $12 per test (whichever is lower).
- Insurers must cover, without cost sharing, COVID-19 tests for asymptomatic individuals regardless of whether a patient has symptoms or was exposed to COVID-19. To be eligible, covered individuals will not need a prescription, an order from a health care provider or a clinical assessment for their tests to be covered.
- Insurers can, but are not required to, reimburse enrollees for OTC COVID-19 tests purchased prior to the Jan. 15 effective date of the guidance.
Although the requirement goes into effect on January 15, it is almost certain it will take most insurers some time to arrange for tests directly and establish a process for reimbursing enrollees for the cost of these tests.
A list of frequently asked questions can be found in the guidance and also HERE. It is highly recommended that you seek further clarification from your insurer as you communicate with employees about this new requirement, including a list of preferred in-network providers where OTC COVID-19 tests can be secured without charge.