Insurance companies and group health plans must cover the cost of over-the-counter, at-home rapid COVID-19 tests for people with private health coverage, starting Jan. 15, the Biden administration announced Monday.
“The new coverage requirement means that most consumers with private health coverage can go online or to a pharmacy or store, buy a test, and either get it paid for up front by their health plan, or get reimbursed for the cost by submitting a claim to their plan,” reads a statement from the U.S. Department of Health and Human Services (HHS). “This requirement incentivizes insurers to cover these costs up front and ensures individuals do not need an order from their health care provider to access these tests for free.”
Insurance companies and health plans must cover eight over-the-counter, at-home tests per month per person. “That means a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month,” according to the HHS statement.
There will be “no limit” on the number of tests, including at-home COVID-19 tests, that insurers or health plans must cover, if a health care provider orders or administers it after a clinical assessment, HHS stipulated.
“Over-the-counter test purchases will be covered in the commercial market without the need for a health care provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments or coinsurance, prior authorization, or other medical management requirements,” according to the department.
“When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12),” it adds.
HHS Secretary Xavier Becerra said the latest move is in addition to the Biden administration’s effort to purchase 500 million COVID-19 tests and send them to Americans who need them, free of charge. Initial contracts to kickstart the delivery of the tests are funded through taxpayer money as part of the American Rescue Plan Act that Biden signed into law in March 2021.
“By requiring private health plans to cover people’s at-home tests, we are further expanding Americans’ ability to get tests for free when they need them,” Becerra said in a statement on Monday.
When enquired about what incentives were offered or are being offered to insurers or health plans as part of the requirement, a spokesperson from the Centers for Medicare and Medicaid Services (CMS) told The Epoch Times that if the plan or insurer sets up a direct coverage program such that covered individuals can get their tests’ cost covered up front, then it is permitted to limit the reimbursement for tests purchased outside of the plan or insurer’s network to $12 per test—or the actual price of the test, if less.
“If the plan or insurer does not set up a process through which individuals can obtain test with no upfront costs, then the plan and insurer must reimburse in the full cost of the test, even if the test costs more than $12,” the CMS spokesperson added.
Many commercially available at-home tests run about $12 or less per test.
The Biden administration in 2021 required state Medicaid and Children’s Health Insurance Program (CHIP) programs to cover all types of FDA-authorized COVID-19 tests, including at-home tests, without cost sharing.
“Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests, with no beneficiary cost sharing when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional,” according to HHS. “People enrolled in a Medicare Advantage plan should check with their plan to see if their plan offers coverage and payment for at-home over-the-counter COVID-19 tests.”
The Biden administration has taken on other efforts to open up access to COVID-19 testing. HHS is providing up to 50 million free at-home tests to community health centers and Medicare-certified health clinics to distribute to patients at no cost to them. The department has also established more than 10,000 free pharmacy testing sites across the United States.
Editor’s note: This article has been updated with a statement from the Centers for Medicare and Medicaid Services.