Feds to require group health plans to cover at-home COVID-19 testing | Fisher Phillips

Three federal agencies have just teamed up to release guidelines that will require group health plans to pay for over-the-counter COVID-19 home tests approved by the U.S. Food and Drug Administration and purchased on January 15, 2022 or after. , but are not obligated to pay for OTC COVID-19 tests purchased before January 15. Here’s what group health plan sponsors need to know about the latest COVID-19 testing coverage mandate released on January 10.

Summary of the new rule

The new rule – announced by the Department of Labor, the Department of Health and Human Services (HHS) and the Treasury Department – ​​requires plans either to arrange to provide free OTC COVID-19 tests at the point of sale using a normal pharmacy plan or retail network or drop-shipping system, or to reimburse testing costs after purchase. When a plan requires reimbursement for an OTC COVID-19 test, reasonable proof of purchase may include the UPC code to verify the item is FDA cleared, or a receipt showing the date of purchase and price.

Plans should take reasonable steps to ensure covered individuals can access OTC COVID-19 testing through an adequate number of in-person and online outlets. Plans must also provide covered persons with the dates when the direct coverage program is available and a list of participating retailers or other locations.

Although the price of OTC COVID-19 tests varies and can add up quickly, the guidelines create a safe harbor that will allow a plan that has organized a network to provide free OTC COVID-19 tests to limit reimbursement of any out-of-network purchase at the lower of the cost of the test or $12 per test. However, a plan cannot enforce this limit if, for example, it cannot provide free OTC COVID-19 testing due to much longer lead times for testing than for other items covered by the plan. In this case, a plan cannot deny coverage or set limits on the reimbursement amount for any OTC COVID-19 test obtained by covered individuals, including tests purchased from out-of-network vendors. Finally, if a plan does not have a network in place to provide free OTC COVID-19 testing at the point of sale, it must reimburse the full cost of an eligible OTC COVID-19 test purchased by a covered person.

Each covered person can get up to eight OTC COVID-19 tests per month, so a family of four would be limited to 32 tests per month. Limits apply assuming a plan does not impose any cost-sharing requirements, prior authorization, or other medical management conditions upon receiving an OTC COVID-19 test.

Does not cover required workplace testing

The OTC COVID-19 Testing Mandate does not apply to testing required for employment purposes. So when an employer requires employees to submit COVID-19 test results as a condition of employment, the plans are not necessary to cover the costs under the new rules. Group health plans may take reasonable steps to ensure that an OTC COVID-19 test for which a covered person has purchased a test for their own use (or for use by another covered member of the ‘individual). For example, a plan or issuer could require an individual to certify in writing that they purchased the OTC COVID-19 test for personal use, and not for employment purposes, and not for resale. , and the cost has not been (and will not be) reimbursed by another source.

What should you do?

Sponsors of group health insurance plans should coordinate with their insurers and third-party administrators to determine how they will comply with the new mandate. This is especially true if they plan to provide the required tests free of charge through their pharmacy network or direct-to-consumer program. They should also be prepared to communicate details regarding how and where participants can access OTC COVID-19 testing under the plan.

Individuals will likely welcome the recent announcement regarding OTC COVID-19 testing costs, but employers face many challenges and questions about how the new mandate will work in practice.

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