Earlier this year, The Departments of Health and Human Services, Labor, and Treasury issued guidance that health plans, including employer-sponsored group health plans, must cover the costs of certain at-home COVID-19 tests purchased on or after January 15, 2022. The costs can be covered by paying the retailer selling the tests directly or by reimbursing a participant for the costs of up to eight at-home tests per participant every month. (NOTE: Plans are not, however, required to cover the cost of employer-required COVID testing.)

Which tests qualify for reimbursement?

Tests can be purchased without a doctor’s order and plans cannot require that they be purchased from preferred pharmacies or retailers. While this covers nearly all at-home tests on the market, they must meet at least one of the requirements below to be reimbursable:

  • Tests approved by the FDA. (Here is a list of those that are approved by the FDA.)
  • A developer has requested an emergency use authorization from the FDA.
  • Tests authorized by a state that has notified the Department of Health & Human Services of its intention to review the test.
  • Other tests that HHS determines appropriate. (Yes, we realize that is an all-encompassing statement.)

Is there a limit on how much must be reimbursed?

Group health plans are allowed to limit reimbursement to the actual cost of the test, or $12 per test, whichever is lower as long as:

  • The plan provides direct coverage by reimbursing the pharmacy or retailer that sells the test.
  • Plan participants must have a way to purchase the tests from in-person or online locations.
  • The plan informs participants on how to purchase covered at-home tests that are directly covered.

If all the above requirements are met, plans can impose cost-sharing on the tests if they are purchased from non-preferred retailers or pharmacies and exceed $12 per test. Keep in mind too, that plans must also cover reasonable shipping and handling fees, as well as sales tax in states where that would apply.

How can plans reasonably prevent fraud?

Plans can take reasonable steps – such as requesting receipts – to confirm that tests not directly covered are specifically for at-home, personal use. Additionally, participants can be asked to substantiate that the tests are being purchased for personal use and not being resold or reimbursed by another source, like an employer.

At this time, there is no end date on this coverage requirement, but as new information or updates are provided, we will share them with you.

About the Author:

Adam C. Meier TMDG Healthcare Assurance and Risk ConsultingAdam C. Meier, CPA, CEBS, GBA, RPA | Manager
Adam primarily provides consulting services to jumbo local and national self-funded health and welfare plans. He is an industry thought leader who serves on local boards and international committees for the International Society of Certified Employee Benefit Specialists. Adam has experience managing complex engagements and creating value for health and welfare plans by delivering proven solutions that mitigate operational and compliance risk, hold insurance companies accountable, and recover claim overpayments.