Federal Guidance on Coverage of Over-the-Counter COVID Tests
Federal Guidance on Coverage of Over-the-Counter COVID Tests
- Starting January 15, 2022, group health plans and issuers must cover FDA-approved OTC COVID-19 tests obtained without the involvement of a health care provider without imposing any cost-sharing requirements, prior authorization, or other medical management requirements.
- Coverage of OTC COVID-19 tests is no longer limited to situations in which the individual has an order or individualized clinical assessment from a health care provider. However, plans and issuers are not required to provide coverage of COVID-19 testing for employment purposes.
- A plan or issuer may require an enrollee to pay for the OTC test and submit a claim for reimbursement. Plans may also set up networks of preferred pharmacies and direct-to-consumer shipping programs to provide enrollees with tests without up-front costs; plans that do that may limit reimbursement to tests purchased elsewhere to $12/test. Plans and issuers that cannot set up such networks will be liable for an enrollee’s total out-of-pocket costs.
- Plans that use this direct coverage program must take reasonable steps to ensure that enrollees have adequate access to OTC COVID-19 tests through an adequate number of retail locations (including both in-person and online locations)
- A plan can limit the number of OTC COVID-19 tests covered for each enrollee to eight per 30-day period (or per calendar month). Plans cannot limit enrollees to a smaller number over a shorter period, e.g., four tests over 15 days.
- A plan or issuer may take reasonable steps to ensure that an enrollee is seeking an OTC COVID-19 test for their personal use as long as such efforts do not create significant barriers for enrollees to obtain these tests. For example, a plan or issuer could require an enrollee to certify tests will not be resold or used by anyone other than the enrollee or other participant covered by the plan; plans may also require an attestation that tests are not for employment purposes.
- It is not reasonable for a plan to require an enrollee to submit multiple documents or take numerous steps that unduly delay their access to or reimbursement for tests.
