Health plans

Employer health plans will soon have to pay for COVID-19 home testing

President Joe Biden’s nine-point action plan for COVID-19, released on December 2, orders federal agencies to pass regulations requiring group health plans and insurers to cover or reimburse costs of COVID early on. home over-the-counter (OTC) -19 tests without requiring health plan participants to pay a portion of the amount.

“To expand the access and affordability of home COVID-19 testing, the departments of Health and Human Services, Labor and the Treasury will issue guidelines by January 15 to clarify that people who purchase OTC COVID-19 diagnostic tests will be able to claim reimbursement from their group health plan or health insurance issuer and have insurance covering costs during the public health emergency, ”according to the announcement from the White House.

Human resources consulting firm Mercer explained, “Under existing guidelines (see FAQ Part 43, Q / A-4), home COVID testing should be covered without cost sharing of participants, but only when they are ordered by a treating health care provider who has determined the test to be medically appropriate based on currently accepted standards of medical practice. “

Mercer noted that “Medicare plans and group insurers
can (but are not
obligatory a) Provide home testing coverage without cost sharing of participants, even in the absence of a determination by a health care provider of medical necessity. While we await important details, it seems entirely possible that the next guidance will significantly expand the scope of the required coverage of in-home COVID testing without cost-sharing of participants, in short, eliminating the need to involve a provider. health care. “

Awaiting orientation

The consulting firm also considered questions that the next guidance should answer, such as:

  • Can group health plans impose limits (such as number, frequency, or dollar caps) on coverage and reimbursement for home testing without cost sharing of participants?
  • Will the home test be fully covered at the point of sale, Or will attendees have to prepay and then submit claims?
  • Should the home test be monitored by a healthcare professional to be eligible for coverage without participant cost sharing?

The New York Times reported that “reimbursement for COVID tests will not be retroactive, meaning consumers cannot submit receipts for what they have already purchased” and it was “unclear whether the government will limit the reimbursements per person “.

Value of home tests

Dr Mark Pandori, director of the Nevada State Public Health Laboratory, recently told the ABC News branch in Reno, Nevada, that home testing “would provide individuals and groups with the intelligence they need to behave responsibly in matters of public health. way. “He noted that if coverage is not provided at the point of sale, then” people with private health insurance will need to first purchase the test, which can cost more than $ 20 for a package of. two, then submit the receipt for reimbursement. “, which could” be a barrier for some people … especially for people for whom this amount of money is important. “

He also noted that “Different antigen tests have different qualities. These are tests that are underperforming when it comes to detecting very small amounts of the virus. They will miss out on positive cases where people are. have very small amounts of the virus in their nose or throat. “Although not infallible, they should, however, show a positive result if patients have a significant viral load and” pose a danger to society at this time. Stadium”.

Vaccine and therapeutic coverage in progress

Julia Vander Weele, a lawyer in Spencer Fane’s office in Kansas City, Missouri, recently recalled on her blog that under the CARES Act (Coronavirus Aid, Relief, and Economic Security), group health plans without rights acquired must cover COVID-19 vaccines. without cost sharing when a vaccine is authorized or approved.

Although COVID-19 treatment is not mandatory without cost sharing, she noted, “some employers initially extended 100% cost sharing arrangements to treatment of the disease itself. However, given the wide availability of the vaccine, some of those same employers have now decided to end the more generous coverage arrangements. “

However, she indicated that “the exception to HIPAA [the Health Insurance Portability and Accountability Act’s] the prohibition on discrimination based on a health factor only applies to premium discounts, rebates and cost-sharing mechanisms ”, and that plans cannot completely“ deny eligibility for benefits or to coverage depending on whether an individual obtains a COVID-19 vaccine or not ”.