On January 10, 2022, the Departments of Health and Human Services, Labor and the Treasury issued joint guidance, in the form of Frequently Asked Questions, for insurers about coverage of over the counter (OTC) COVID-19 testing. Insurers must cover OTC (i.e., at home) COVID-19 tests on or after January 15, 2022 and during the COVID-19 public health emergency. Depending on the plan, an insurer may require an individual to submit a claim for reimbursement to the insurance company or the tests may be directly covered at the point of sale.
There are a few limitations specified in this guidance. Insurers are not required to provide coverage of testing that is for employment purposes, only for the purpose of diagnosing COVID-19. An insurer may limit the number of at home tests to 8 tests per 30-day period if two criteria are met. These criteria are (1) if the plan provides coverage for COVID-19 tests without cost-sharing, and (2) if the plan provides direct coverage of tests at the point of sale, so that an individual is not required to seek reimbursement post purchase. Insurers that meet these criteria by providing direct coverage through their pharmacy networks and through a direct to consumer shipping program can limit reimbursement for OTC COVID-19 test purchased from non-preferred pharmacies and other retailers to the actual cost of the test or $12 per test, whichever is less.
Insurers may take reasonable actions to prevent, detect and address fraud and abuse, such as a COVID-19 test provided by the plan being resold. Insurers can also require reasonable documentation as proof of purchase for reimbursement purposes, such as the UPC code from the COVID-19 test package and/or a receipt from the seller. Insurers may provide education and information resources to support consumers seeking at home COVID-19 testing, as long as the resources make it clear that the insurer provides coverage for all OTC tests.
You should check with your health plan or its member services unit to understand the plan’s policies regarding coverage for OTC COVID-19 testing.
Last Updated: January 31, 2022