Effective January 15, 2022, the Biden Administration issued guidance requiring all group health plans and health insurers to cover FDA-authorized and approved over-the-counter (OTC) COVID-19 tests without member cost until the end of the federal Coronavirus Public Health Emergency, which has been extended until April 16, 2022.

What are the OTC requirements?

• Allows consumers with commercial health coverage to seek reimbursement from their health plan for OTC tests they purchase online or in-person without the direct involvement of a health care provider.

• Requires health plans to cover, without cost sharing, up to eight OTC tests per member per 30 days* (if kits contain two tests, then no more than four kits per 30 days). Consumers may submit for reimbursement up to 2 per kit or up to 4 per two test kits. FSA and HSA funds may be used to pay for test expenses that are above 2 per test but may not pay for their tests if under this amount using FSA or HSA dollars. Some carriers have shared that they have chosen a preferred pharmacy that will provide direct coverage if purchased there. For members who purchase outside of the preferred pharmacy partner, the carrier will reimburse up to an allowed amount and need to submit a claim form.

• Maintains the policy that plans are only required to cover free rapid tests intended for diagnosis or treatment (and not covered for routine screenings for employment, school, or recreational purposes).

• While this test quantity limit applies to OTC COVID-19 at-home tests purchased without the involvement of a health care provider, plans continue to cover COVID-19 tests performed by health care providers and those tests are not subject to this quantity limit.

Who is eligible?

• To be eligible for coverage, at-home COVID tests must be purchased by the participant, beneficiary, or enrollee for personal use, and not for employment purposes nor resale.

Where can members purchase their OTC kits?

• Customers may receive reimbursement for up to eight OTC COVID-19 at-home test kits per covered individual in the household per 30-day period (or per calendar month) without a health care provider order or individualized clinical assessment. They can purchase at retailers or online.

As Americans sigh a sense of relief for this financial support, carriers are vigorously working to finalize the logistics on executing these reimbursements would be executed.

Carriers have the option to choose direct coverage or direct member reimbursement and are encouraged to provide direct coverage for these over-the-counter tests. This will help mitigate the need for participants to pay up front and submit a claim with the receipt for reimbursement. However, under the guidelines, insurance companies are permitted to require plan participants to pay up front and submit a claim with the receipt for reimbursement.

Most carriers are opting for the direct coverage option, with a pharmacy benefit, whereby consumers would have the tests covered for free at the point of purchase.

As carriers work with retailers on getting this up-and-running, reimbursements are currently being handled through a direct claim reimbursement, whereby members would pay up-front, fill out and submit the appropriate form and get reimbursed.

What we currently don’t know:

Some carriers are still evaluating the safe harbor rules and will provide updated communications if necessary. According to the federal mandate, health plans must reimburse the costs of diagnostic OTC testing, regardless of where it was obtained (in- or out-of-network). The federal government is not expecting the preferred pharmacies in a plan’s “direct coverage” solution to represent the entire plan’s entire pharmacy network.

Carrier Reimbursement Summary

Check out the Carrier OTC Reimbursement Overview that provides an overview for all carriers including Aetna, Anthem, Blue Shield, Cigna, Kaiser, and United Healthcare and will be continuously updated with new information.

At Newfront, we are actively monitoring the situation and will continue to post updates, including carrier-specific information, as information becomes available. At this time, carriers have shared that they plan to release additional information on January 19th, 2022, so please continue to check back for updates at our COVID-19 Resources page.