On January 10th, various federal agencies issued guidance in the form of Frequently Asked Questions (FAQs) around the Biden administration’s mandate that group health plans must cover over-the-counter (OTC) COVID-19 tests. The mandate takes effect on January 15th and stipulates that there be no member cost share or copays when purchasing an OTC test. In a nutshell, health plans must cover eight individual at-home OTC COVID-19 tests per person enrolled in the plan per month. That means a family of four can get 32 tests per month for free. Importantly, this mandate does not include surveillance tests one may need for work.
Below are some key headlines related to the new requirement:
Effective Date: The requirement is effective on January 15, 2022, and continues for the duration of the public health emergency. Coverage may, but is not required to, be provided for OTC COVID-19 tests purchased before January 15, 2022.
Per Test Dollar Limit/Reimbursement: Plans must provide coverage without out-of-pocket expenses to the participant. The plan can provide the coverage by reimbursing sellers (i.e., CVS, Walgreens, etc.) of OTC COVID-19 tests directly (“direct coverage”) or by requiring participants who purchase an OTC COVID-19 test to submit a claim for reimbursement to the plan. The agencies strongly encourage, but do not require, direct coverage. The requirement stipulates that plan members not be limited to having to use a network pharmacy. Also, under a safe harbor, the agencies provide that plans may limit reimbursement of tests purchased outside the direct coverage (i.e., when one files a claim) to $12 per test or the cost of the test, if lower. CMS has issued Q&As for employees entitled “How to Get Your At-Home Over-the-Counter COVID-19 Test for Free.” These Q&As describe the test cost limits applicable when a plan sets up a network of convenient options such as pharmacies or retailers, including online retailers, in which individuals on their plans can get their tests’ cost covered up front (at the point of sale), versus where a plan does not set up a process through which individuals can obtain tests with no upfront costs.
Quantity Limit: Plans may limit the number of tests reimbursed to no less than eight OTC COVID-19 tests per covered individual per 30-day period (or per calendar month). This applies to OTC COVID-19 tests purchased without the involvement of a health care provider.
Scope of Requirement: Until now, it has been generally understood that group health plans were required to cover COVID-19 “diagnostic” tests when provided by a medical provider. Under the new requirement, there will be no medical provider involved. However, the new requirement continues to only apply to “diagnostic” OTC COVID-19 tests, primarily intended for individualized diagnosis or treatment of COVID-19. Testing that is for employment (surveillance) purposes is not considered diagnostic and so tests for employment purposes do not fall under this new requirement. The requirements allow plans to require attestation that the test was purchased for the covered individual, is not for employment purposes, has not and will not be reimbursed by another source and is not for resale. Plans may also require reasonable documentation of proof of purchase.
Next Steps Conner Strong & Buckelew is working with the various health plans and pharmacy benefit managers (“PBMs”) to understand their systems and processes for adhering to this new requirement. Since the requirement takes effect so quickly, we anticipate some health plans and PBMs may experience delays at the onset of the rule.
We are working to provide information on how each health plan and PBM will administer this new mandate and will issue updates accordingly. If you have any immediate questions with this new requirement, please contact your Conner Strong & Buckelew representative toll-free at 1-877-861-3220. For a complete list of Legislative Updates issued by Conner Strong & Buckelew, visit our online Resource Center.