OTC COVID-19 Testing Guidance Issued
Group Health Plans Must Cover OTC Covid Tests Effective January 15, 2022.
On January 11, 2022, The Departments of Health & Human Services, Labor and Treasury issued guidance, via a series of FAQs, indicating that group health plans must cover over-the-counter (OTC) COVID tests beginning January 15, 2022; and for the duration of the public health emergency.
This new information is based on provisions in the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (CARES) Act requiring group health plans to cover diagnostic COVID tests without cost-sharing. Until now, that language had generally been understood to require coverage of tests administered by a medical provider.
Group health plans (and health insurers) are required to cover diagnostic OTC COVID tests without imposing cost-sharing, prior authorization, etc. This means plans must provide coverage without out-of-pocket expenses to the participant. The plan can provide the coverage by reimbursing sellers of OTC COVID tests directly or by requiring participants who purchase an OTC COVID test to submit a claim for reimbursement.
Important Note: This requirement only applies to “diagnostic” OTC COVID tests. Testing for employment purposes is not considered diagnostic, and is not included.
Quantity & Dollar Limit
Plans may limit the number of tests reimbursed to no less than eight (8) OTC COVID tests per covered individual per 30-day period (or calendar month).
Plans that provide direct coverage of OTC COVID tests may not limit coverage to only tests provided through preferred pharmacies or other retailers that are part of the direct coverage program. However, under a safe harbor, the agencies state that plans may limit reimbursement of tests purchased outside the direct coverage program to $12 (or the cost of the test, if lower).* The agencies also note that plans must take reasonable steps to ensure participants have adequate access to tests under the direct coverage option.
*The safe harbor applies if the plan provides tests through its pharmacy network and/or a direct-to-consumer shipping program, under which there is no upfront out-of-pocket expenditure by the participant.
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