February 16, 2022
On February 4, 2022, federal agencies released additional FAQs related to coverage of over the counter (“OTC”) COVID-19 tests by group health plans and health insurance carriers. The FAQs are intended to clarify the previous FAQs released on January 10, 2022.
On January 10, 2022, the agencies released initial guidance for plans and carriers, which required them to cover FDA approved at-home, OTC COVID-19 tests without cost sharing, prior authorization, or medical management, and without the need for a prescription or recommendation of a health care provider. These requirements apply during the COVID-19 public health emergency. Notably, plans and carriers are not required to cover OTC COVID-19 tests purchased or used for workplace testing/employment purposes.
Plans and carriers may reimburse participants for their purchase upon submission of a claim or by reimbursing the entity who sold the test directly. The guidance provided for two safe harbors, which permit plans and carriers to:
In order to limit reimbursements for tests purchased from non-preferred providers, plans must ensure there are an adequate number of retail locations (in-person and online) with access to OTC COVID-19 tests and communicate necessary information about the direct coverage program, including when it is available and which retail pharmacies are available.
The guidance issued on February 4, 2022 (which is generally effective prospectively for purposes of the first 5 bullets below), helps clarify some of the requirements in the initial guidance, and provides the following:
Plans and carriers can use this additional guidance to tailor their OTC COVID-19 test coverage, and employers are encouraged to work directly with their carriers and TPAs to ensure they are adequately communicating their OTC COVID-19 testing coverage requirements to participants.
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