Group Insurers Required to Cover OTC COVID Tests 1-15-22

January 13 2022

Categories: HR Solutions

Group Insurers Required to Cover OTC COVID Tests 1-15-22

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.

Legal Requirements

  • 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

Plan Options
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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