The Biden Administration recently issued an Order requiring insurance companies and group health plans to cover the cost of at-home COVID-19 tests. The Administration did not give much time to prepare as it required insurance companies and group health plans to cover the cost of these tests starting January 15th.
Preferred Pharmacies or Retailers: On January 10th, the Department of Labor (“DOL”) published a Frequently Asked Questions page to help implement the Administration’s Order. There, the DOL explained that plans and insurers cannot limit coverage to tests that are only provided through preferred pharmacies or other retailers, and that participants, beneficiaries, and enrollees should receive reasonable reimbursement for OTC COVID-19 tests purchased from pharmacies or retailers of their choice. However, plans and insurers can make tests available through, and encourage the use of, preferred retailers.
Reimbursement: The DOL also explained that plans or issuers are not required to provide coverage by reimbursing sellers of OTC COVID-19 tests directly (“direct coverage”) but may, instead, require a participant, beneficiary, or enrollee who purchases an OTC COVID-19 test to submit a claim for reimbursement to the plan or issuer. However, the DOL also strongly encourages plans or issuers to provide direct coverage for OTC COVID-19 tests to participants, beneficiaries, and enrollees by reimbursing sellers directly.
Limit on the Number of Tests: Under the Administration’s Order, 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. However, OTC COVID-19 tests purchased without an individualized clinical assessment may be capped at no less than 8 tests per 30-day period (or per calendar month). This means that a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month. When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12).