On January 10, the Biden Administration finalized guidance for commercial insurance coverage of at-home diagnostic tests or over-the-counter (OTC) COVID-19 testing.
Effective January 15, 2022, private health insurers are required to cover up to eight at-home COVID-19 tests per 30 days (or per month) for plan members absent involvement of a health care provider and without cost sharing.
The new OTC coverage requirement:
Allows consumers with commercial health coverage to seek reimbursement from their commercial health plan for OTC tests they purchase online or in-person without the direct involvement of a health care provider.
- Requires health plans to cover, without cost sharing, no less than 8 OTC tests per covered individual per 30 days (or per month) (i.e., if testing kits contain 2 tests per kit, then no less than 4 kits per month) in addition to all diagnostic tests ordered by a provider.
- Allows heath plans to pay for OTC tests up front (via “direct coverage” or purchase) or reimburse individuals via the claims process.
- Allows plans to limit reimbursement to the lesser of $12 per test or the actual price (whichever is lower), if a plan provides direct coverage of OTC tests.
- Maintains the policy that plans are not obligated to cover routine screening for employment purposes and allows plans to require a patient attestation.
The guidance applies to group health plans and health insurance issuers offering group or individual health insurance coverage, including grandfathered health plans and Federal Employees Health Benefits plans (FEHB), and is effective January 15, 2022 through the public health emergency. The guidance does not apply to Medicare or Medicaid.
Plans are not required to provide direct coverage and may instead opt to require a plan member to submit a claim for plan reimbursement if they purchase an OTC COVID-19 test.