On January 10, 2022, the Departments of Labor, Health and Human Services, and Treasury issued FAQs Part 51 regarding the requirement for health plans to cover FDA-approved, over-the-counter (OTC) COVID-19 diagnostic testing (“OTC COVID Tests”). This requirement is effective for OTC COVID Tests purchased on and after January 15, 2022, and will last through the COVID-19 public emergency period. The OTC COVID Test coverage rules do not apply to excepted benefits (such as limited-scope dental plans or certain employee assistance plans) and group health plans that do not cover at least two employees who are current employees (such as retiree-only plans).
Beginning January 15, 2022, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test will be able to have those test costs covered by their plan or insurance. In order to be covered, the tests must be authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA). At-home tests are available for sale around the U.S. Check with local retailers and pharmacies to see where at-home tests are available. To verify if a test is approved by the FDA, see this list of approved at-home test kits and scroll down to view a searchable table of approved tests.
OTC COVID Test purchases will be covered in the commercial market 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 coinsurance, prior authorization, or other medical management requirements.
Insurance companies and health plans are required to cover 8 free over-the-counter at-home tests per covered individual per month. That means 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. 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 and insurers can take steps to prevent fraud to ensure that the tests for which a covered individual seeks coverage were purchased for the individual’s own personal use (or use by a family member, another participant, beneficiary, or enrollee covered under the plan).
Americans will have the option of buying tests at a store or online and then requesting reimbursement from their health insurance provider. Insurers are being incentivized to work with pharmacies and retailers to develop plans to cover the cost of the tests with no out-of-pocket cost to consumers, but such programs will not be immediately widespread. For example, an insurer can make arrangements with a pharmacy so that covered individuals can pick up tests free at the pharmacy locations. In this situation, if a covered individual purchases a test from a retailer other than the pharmacy, the insurer is only required to reimburse up to $12 for the test. The insurer can reimburse more if they wish.
Because the OTC COVID Tests are now covered under the health plan on or after January 15, 2022, covered individuals should not seek reimbursement for these tests from their health flexible spending accounts (HFSA), health savings accounts (HSA), or health reimbursement arrangements (HRA). They can seek reimbursement from these accounts if the test was purchased before January 15, 2022. Many participants purchase these tests with their HFSA/HSA/HRA benefit cards. HFSA/HSA/HRA participants should be alerted that they should not purchase tests with their benefit cards or seek reimbursement from the HFSA/HRA service provider or reimburse themselves from their HSA, but rather seek reimbursement from their insurer.
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