We are in the middle of yet another COVID surge. Testing sites have lines blocks long and at-home COVID tests are flying off the shelves as soon as the shelf is replenished. In response to the latest surge, the Department of Labor, Health and Human Services, and the Treasury jointly released guidance yesterday that requires group health plans to reimburse plan participants for the cost of at-home COVID tests. This is welcome news for individuals, if they can find a test to purchase.
The Families First Coronavirus Response Act, CARES Act, and subsequent guidance already required group health plans to cover costs of testing when ordered by an attending health care provider who had determined that the test is medically appropriate for an individual. Last month President Biden announced that future guidance was forthcoming, and effective January 15, 2022, group health plans must now cover costs of over-the-counter COVID testing for participants, beneficiaries, and enrollees of a plan, even without an order or individualized clinical assessment from a health care provider.
Group health plans must cover over-the-counter COVID tests without imposing any cost-sharing requirements, prior authorization, or other medical management requirements. Although recommended, the new guidance does not require a plan to provide coverage by reimbursing sellers directly, and plans may instead require a participant who purchases an over-the-counter COVID test to submit a claim for reimbursement. Plans will satisfy the guidance requirement by providing direct coverage through its pharmacy network (assuming adequate access), and otherwise may limit reimbursement for COVID tests from non-preferred pharmacies or other retailer to no less than the actual price, or $12 per test (whichever is lower). Lastly, plans can limit the number of over-the-counter COVID tests covered, but plans must at least cover a minimum of 8 tests per calendar month for each participant, beneficiary, and enrollee in the plan. That means a family of 4 could receive up to 32 home tests a month for free! I applaud any person that could actually find 4, yet alone 32 tests to purchase in a month.
The guidance will be effective from January 15, 2021 through the end of the public health emergency. If you have any questions on implementing this guidance, please contact any of our Employee Benefits attorneys.
