Author: Shelly Hodges-Konys, Director of Compliance
The latest surge in the COVID-19 pandemic led President Biden to announce on December 2, 2021, that individuals who purchase at-home COVID-19 test kits would be able to have those expenses reimbursed by their group health plans. Insurers and employer plan sponsors have been wondering what that means for plans, plan participants, and plan cost. On one hand, the announcement sounded like a present providing more convenient testing options. And, on the other hand, it also created visions of a lump of coal in a stocking through potential increases in insurance and plan expenses.
In response, the Departments (Health and Human Services, Labor, and Treasury) released guidance on Monday, January 10th, applicable to the implementation of the Families First Coronavirus Response Act (FFCRA), the Coronavirus Aid, Relief, and Economic Security Act (CARES), and the Affordable Care Act (ACA) on the coverage requirement available here.
Coverage and Payment
The guidance requires coverage of at-home or over-the-counter COVID tests without a prescription, meaning that a prescription or the direction of a healthcare provider is unnecessary. Tests must be covered without out-of-pocket cost to plan participants, prior authorization, or other medical management criteria beginning on January 15, 2022. Testing may be covered by:
- Direct reimbursement by the plan to the seller of the COVID test (which is strongly encouraged); or
- By reimbursement to the plan participant after providing proof of purchase (receipt) and submitting request for reimbursement to the plan.
Coverage of at home COVID testing is required through the duration of the public health emergency.
Limitations on Reimbursement and Number of Tests
The guidance allows plans to limit the amount of reimbursement for at-home tests if:
- The plan provides direct reimbursement of at-home tests through its pharmacy network and direct shipping program; and
- The plan takes steps to ensure that plan participants have adequate access to tests through both retail and online locations.
If the above conditions are met, reimbursement of COVID tests received through any other provider may be limited to the lesser of the actual cost of the test or $12.
Additionally, plans may limit the number of COVID tests purchased or received without the direction of a health care provider to no less than 8 tests per covered plan participant per 30-day period (or per calendar month). Plans may also attempt to prevent fraud and abuse by requiring a brief attestation from the participant that the test is being purchased for personal use. However, plans must ensure that such attestation does not create a significant barrier to receiving the test.
Employer Action
Employers should be aware of how their insurer or claims administrator (if self-funded) will provide coverage of at-home COVID tests to plan participants. Insurers and claims administrators are in the process of responding to the guidance and finalizing their plans. HORAN has reached out to insurers and claims administrators on your behalf and will provide additional information as soon as it becomes available.
Please reach out to your HORAN representative with additional questions at 800.544.8306.
The information contained in this document is informational only and is not intended as, nor should it be construed as, legal or accounting advice. Neither HORAN nor its consultants provide legal, tax nor accounting advice of any kind. We make no legal representation, nor do we take legal responsibility of any kind regarding regulatory compliance. Please consult your counsel for a definitive interpretation of current statute and regulation and their impact on you and your organization.
