Health plans

New COVID-19 guidelines: Government requires health plans to cover COVID-19 home testing | Faegre Drinker Biddle & Reath LLP

On January 10, 2022, the Departments of Health and Human Services, Labor, and Treasury issued guidance regarding the requirement for a group health plan to cover the cost of over-the-counter COVID-19 testing at home. effective January 15, 2022. a new coverage requirement means registrants can go online or at a pharmacy and purchase an FDA-approved over-the-counter COVID-19 diagnostic test and either have their health insurance plan, or be reimbursed by submitting a claim without any cost-sharing requirements (such as deductibles, co-payments, or coinsurance). The guidelines provide that from January 15, 2022 until the end of the declared public health emergency, plans must cover at least eight (8) over-the-counter home tests per enrolled individual per 30 days (or months calendar) period without assessment or involvement of the service provider. This does not affect the obligation to provide coverage for COVID-19 testing with a provider’s participation or prescription.

The table below provides more details on the required coverage of COVID-19 home testing as well as an overview of the required coverage of other COVID-19 related tests, vaccines and treatments.

Required coverage of COVID-19 benefits as of January 15, 2022

Benefit related to COVID-19 Are group health plans* required to cover this benefit? Should the benefit be provided without cost sharing, prior authorization or other medical management requirements? comments
COVID-19 vaccinations (including boosters) Yes – Plans must cover any COVID-19 vaccine cleared or approved by the FDA immediately after approval or clearance Yes, whether administered by an in-network or off-network provider
  • Considered preventative care for purposes of determining if a health plan qualifies as a High Deductible Health Plan (“HDHP”)
COVID-19 testing

and related diagnostic services

(other than OTC testing)

Yes (for the duration of the health emergency) –
  • Related tests/services performed for diagnostic purposes should be covered
  • Related tests/services performed for workplace safety, return to work, or other purposes not intended for diagnosis or treatment are not required to be covered
  • Plans cannot require the presence of symptoms or suspected exposure as a condition of coverage
  • Plans may require a prescription from a healthcare provider or clinical evaluation (although these requirements may not be required for OTC testing)
Yes – Plans cannot use medical screening criteria to impose cost sharing
  • HDHPs may provide benefits associated with COVID-19 testing and treatment prior to meeting the applicable HDHP minimum deductible without affecting covered individuals’ Health Savings Account eligibility.
COVID-19 FDA-Approved Over-the-Counter Home Tests (“OTC Tests”) Yes (from 01/15/22) –
  • A prescription or clinical assessment from a health care provider cannot be required by the Plan
  • Coverage cannot be limited to OTC tests purchased from pharmacies or preferred retailers
  • Plans are not required to provide coverage of OTC tests that are for employment purposes.
Yes –
  • Plans may limit the number of OTC tests covered without cost sharing, but must allow for at least eight (8) tests per 30-day period (or calendar month) per person covered
  • Plans may limit the amount paid for OTC tests obtained from pharmacies and out-of-network retailers at lesser of the actual price of the test, i.e. $12; on condition that (i) the Plan provides direct OTC testing coverage through its pharmacy network and direct-to-consumer program at no cost to participants; and (ii) access to an adequate number of OTC tests is available through direct coverage (depending on the facts and circumstances – this can be discussed with the plan pharmacy manager, e.g. there is no probably not enough OTC tests currently available to answer this test)
  • Plans can choose to pay OTC test sellers directly (“direct coverage”) or require the covered person to pay for it at the point of sale and then submit a claim for reimbursement
  • Plans can take steps to prevent, detect and address fraud and abuse (provided the requirements are not too onerous for participants) – the plan could require attestations from participants that OTC tests were purchased for personal use and not for employment or resale, and require documentation showing purchase price and date
Covid-19 treatment No – there are no federal requirements to cover specific items and services needed to treat complications from COVID-19. No – plan rules for cost-sharing, pre-authorization, and other medical management are allowed (although some plans waived cost-sharing, at least before COVID-19 vaccines became available) HIPAA’s prohibition against discrimination based on a health factor would prohibit denying eligibility for benefits or coverage based on whether or not you have had a COVID-19 vaccination

*Different rules may apply to group health plans that are grandfathered under the Affordable Care Act (ACA) or are retiree-only or only provide excluded benefits.