Guidance has been issued regarding the requirements for group health plans and health insurance carriers to cover over-the-counter (OTC) COVID-19 diagnostic tests beginning January 15, 2022.
- Plans and issuers must cover the costs of COVID-19 tests during the COVID-19 public health emergency 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 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.
- Insurance companies and health plans are required to cover 8 OTC at-home tests per covered individual per 30-day period.
- There is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.
- Plans are not required to provide coverage of testing (including an at-home OTC COVID-19 test) that is required by an employer for employment purposes.
See links below for full list of FAQs:
Department of Labor FAQs
Plans and insurance carriers may place some limits on coverage, such as:
- Requiring individuals to purchase a test and submit a claim for reimbursement rather than providing direct coverage to sellers.
- Providing direct coverage through 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).
- Setting limits on the number or frequency of OTC COVID-19 tests that are covered.
- Taking steps to prevent, detect and address fraud and abuse.
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