Starting January 15, 2022, employees and dependents covered by an employer-sponsored health plan can go online, to a pharmacy or store, buy a test approved by U.S. Food and Drug Administration, and either get it paid for upfront by their health plan or get reimbursed for the cost by submitting a claim to their plan.
Doctor’s Authorization Not Required
On January 10th, the Department of Labor’s (DOL) Employee Benefits Security Administration posted a new set of frequently asked questions and answers addressing the new requirement. The FAQs state that OTC test purchases will be covered without the need for a health care provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments or co-insurance, prior authorization, or other medical management requirements.
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), the guidance states.
The coverage requirement applies to the cost of test kits intended for individualized diagnosis of COVID-19. The guidance does not require plans and insurers to cover the cost of routine testing for employment purposes.
Limits on Number of Tests
In addition, the DOL guidance clarifies that health plans and insurance issuers:
- May 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, “plans and issuers are strongly encouraged to provide direct coverage for OTC COVID-19 tests … by reimbursing sellers directly without requiring participants, beneficiaries, or enrollees to provide upfront payment and seek reimbursement.”
- May provide coverage without cost-sharing for at-home tests purchased before Jan. 15 but are not required to do so.
- May set limits on the number or frequency of OTC COVID-19 tests covered without cost-sharing but must allow up to 8 tests per 30-day period (or per calendar month). 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.
- May not limit the number of tests reimbursed at no cost if the tests are ordered by a health care provider following a clinical assessment.
Contact your insurance carrier to determine if your plan will allow you to obtain OTC COVID-19 tests at no charge by providing your health insurance ID card at the pharmacy or if you will need to submit a claim for reimbursement. If you are charged for your test after January 15th, be sure to keep your receipt and submit a claim to your insurance company for reimbursement.
For those individuals without health insurance, President Biden has stated the federal government is purchasing 500 million at-home rapid COVID-19 testing kits that will be sent free of charge to Americans who request them and distributed by mail through a new website. Initially, the delivery was scheduled to begin at the end of January, but that may be extended into February as the U.S. is currently have a shortage of testing kits. More information about this new website is forthcoming.
Provided by SHRM