The Biden administration recently announced new guidance requiring group health insurance plans and insurers to cover the cost of at-home COVID-19 tests beginning on January 15, 2022. This guidance applies to both fully-insured and self-funded insurance plans and the U.S. Department of Labor (DOL) and Centers for Medicare and Medicaid Services (CMS) have been tasked with offering guidance regarding the requirement. Here’s what you need to know:
An Introduction to the Recent Guidance
Per the guidance issued by the DOL and CMS, individuals covered by private health insurance or a group health plan who purchase an at-home COVID-19 test will have the cost of those tests covered by insurance. This is assuming that the at-home COVID-19 test purchased is one that is authorized, cleared, or approved by the U.S. FDA or has emergency use authorization. The guidance requires that insurers cover up to eight free individual COVID-19 tests per covered individual per calendar month.
The Requirements for Health Plans and Insurers
As of now, the DOL and CMS will not take any enforcement action against any plan or issuer that provides direct coverage through a pharmacy network or a direct-to-consumer shipping program and otherwise limits reimbursements for at-home COVID-19 tests. By their definition, direct coverage means that the individual is not required to seek reimbursement after purchasing a test and is not subject to cost-sharing at the point of purchase. Health plans also may not impose prior authorization or medical management requirements on test purchasers.
Plans must take reasonable steps to ensure adequate access to at-home COVID-19 tests. The guidance also states that plans and insurers should ensure that all participants are aware of any information that is needed to help them access COVID-19 testing. Examples of this information would be dates of availability, participating retailers, etc.
In the case of high deductible health plans (HDHPs), IRS Notice 2020-15 provides that a health plan that otherwise satisfies the requirements to be an HDHP will not fail to be an HDHP merely because the health plan provides medical care services and items purchased in relation to testing and treating COVID-19. As such, those individuals will still be eligible to participate in Health Savings Accounts.
At-Home COVID-19 Tests for Those Covered by Medicare and Medicaid
Individuals covered by Medicare already have their COVID-19 diagnostic tests, like PCR and antigen tests, performed with no beneficiary cost-sharing when the test is ordered by a physician, pharmacist, or other authorized healthcare professional. Currently, individuals who are on Medicare will not be able to get their at-home COVID-10 tests reimbursed through the program. Medicaid and Children’s Health Insurance Program plans will be required to cover the full cost of at-home COVID-19 tests.
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