On January 10, 2022, the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively, the Departments) issued FAQs Part 51 explaining that insurance carriers (insurers) and group health plans are required to provide coverage for at-home COVID-19 diagnostic tests at no cost, even without a health care provider’s order. This requirement is effective for tests purchased on or after January 15, 2022 and aims to expand participants’ ability to obtain tests for free amidst the ongoing public health crisis.

Compliance Snapshot

  • Insurers and group health plans are required to cover eight free over-the-counter at-home tests per covered individual per month.
  • If an insurer or group health plan identifies preferred pharmacies or retailers, tests purchased outside of that network are reimbursed up to $12 per individual test.

Background

The FFCRA generally requires insurers and group health plans (including fully insured, self-insured, and level funded plans) to provide coverage for certain items and services related to COVID-19 testing and diagnosis as of March 18, 2020 and through the applicable emergency period (which is currently ongoing with HHS to provide 60 days’ advance notice prior to termination). This coverage must be provided without cost-sharing requirements (including deductibles, copayments, and coinsurance), prior authorization, or other medical management techniques.

Prior guidance explains that COVID-19 tests intended for at-home testing (including tests where the individual performs self-collection of a specimen at home) must be covered without cost-sharing, prior authorization, or other medical management requirements when the test is ordered by a health care provider who has determined the test is medically appropriate. See Q4 of Part 43. This guidance, however, did not address coverage for over-the-counter COVID-19 tests purchased without an order by a health care provider.

Coverage Requirement

Part 51 clarifies that insurers and group health plans (including fully insured, self-insured, and level funded plans) are required to provide coverage for eight at-home over-the-counter COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA), per covered individual per month, without an order from a health care provider. See Q1 through Q3 of Part 51 for additional information. For example, a family of three on the same plan can receive up to twenty-four COVID-19 tests covered by their group health plan per month without cost-sharing. Note that there is no limit on the number of at-home COVID-19 tests if ordered by a health care provider.

Further, insurers and group health plans are incentivized to identify preferred pharmacies or retailers for the purpose of providing coverage of COVID-19 tests. When COVID-19 tests are purchased from such preferred pharmacy or retailer, there will be zero cost to the participant at time of purchase (eliminating the need to submit a claim). If insurers and group health plans identify a preferred network, any COVID-19 test purchased outside of the network is capped at a $12 per test reimbursement (or actual cost of the test, whichever is less). Otherwise, if insurers and group health plans do not identify a preferred network, the entire cost of the COVID-19 test must be reimbursed (and is not limited to a $12 maximum benefit per test).

In addition, the guidance explains that plans are not required to provide coverage for over-the-counter COVID-19 tests that are for employment testing purposes (e.g., weekly testing to comply with an employer’s program or pursuant to the OSHA Emergency Temporary Standard requirement). To that end, an insurer or group health plan may require attestation from a participant indicating that the over-the-counter COVID-19 test is for personal use and not for employment purposes. See Q4 of Part 51.

Employer Action

Employers should do the following:

  • Discuss with their insurers or third-party administrators (as applicable) to confirm compliance with this coverage requirement; and
  • Communicate any coverage changes to employees.

Importantly, enforcement action will not be taken against insurers or group health plans for implementing mid-year coverage changes to comply with this requirement, or for failing to provide 60-day advance notice (applicable for any change to the content of the Summary of Benefits and Coverage) as long as notice of these changes is provided as soon as practicable.

Additional Resources

Diane Cross — Diane is a Client Compliance Consultant for Sequoia, where she works with our clients to optimize and streamline benefits compliance. In her free time, Diane enjoys spending time with her family, live music, and cycling.