How health insurers are covering over-the-counter COVID-19 tests

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Following recent guidance from the Biden Administration, health insurers in the commercial market are covering the costs of over-the-counter COVID-19 tests. 

Under the new guidance, private insurers must cover up to eight Food and Drug Administration-authorized rapid tests per member per month. This averages out to be about two rapid tests per week for those eligible, according to the Kaiser Family Foundation (KFF).

As of Jan. 15, most people with a health plan can go online or to a pharmacy or store to purchase an at-home over-the-counter COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration at no cost, either through reimbursement or free of charge through their insurance, according to the Centers for Medicare and Medicaid Services. This applies to individuals who have purchased their own health plan on have health insurance through their jobs.

The test will either be free directly at the point of sale, if the health plan provides for direct coverage, or by reimbursement if members are charged for the test. Receipts need to be submitted to file a claim with the insurance company for reimbursement. 

If a plan has set up a network of preferred providers to obtain a test with no out-of-pocket expense, a member can still obtain tests from other retailers outside that network. Insurance companies are required to reimburse at a rate of up to $12 per individual test (or the cost of the test, if less than $12).

According to AHIP, the KFF analysis found that nearly half of large health insurance providers are providing ways for members to get their tests directly without having to pay anything out-of-pocket up-front.

This includes the following, AHIP said:

• Independent Health commercial and self-funded plan members can go to their pharmacy, a store or online to obtain an over-the-counter COVID-19 diagnostic test authorized by the FDA. Members who have purchased a test on or after Jan. 15 can log in to their secure MyIH account and submit a claim.
•  L.A. Care members in commercial L.A. Care Covered Plans and the PASC-SEIU Homecare Workers Health Care Plan may obtain up to eight OTC COVID-19 rapid antigen tests per month at no cost, either through an L.A. Care network pharmacy or L.A. Care's mail order pharmacy. At retail locations such as CVS, members must pick up the test through the pharmacy and show their L.A. Care member ID card to verify eligibility. L.A. Care will reimburse members up to $12 for tests purchased outside of an L.A. Care network pharmacy.
• Tufts Health Plan is covering the cost of up to eight OTC COVID-19 tests per member, per month for commercial, Tufts Health Direct, MassHealth, Senior Care Options and Unify members. Tests must be approved or granted emergency use authorization by the FDA. Commercial and Direct Members should visit the Caremark website for the most up-to-date information on participating pharmacies to purchase the tests with no up-front cost.
• Commercial and Direct Members paying for at-home tests out-of-pocket can also print a form and mail it with copies of receipts. Medicaid members can obtain coverage for five branded OTC tests through their pharmacy benefits. Guidance on coverage for MassHealth, Senior Care Options and Unify members will soon be available.
• Western Health Advantage members who purchase an FDA-approved COVID-19 diagnostic test can submit a reimbursement request form, with a scanned receipt, for the cost paid – up to $12 per diagnostic test. Members can also visit a preferred test pickup pharmacy and simply show their WHA ID Card, and the pharmacist will dispense the OTC tests at no charge at time of pickup.

THE LARGER TREND

The Biden Administration on Jan. 10 announced it was requiring insurance companies and group health plans to cover the cost of over-the-counter, at-home COVID-19 tests so people with private health coverage could get them for free starting Jan. 15.

ON THE RECORD

Matt Eyles, president and CEO of AHIP, said: "Health insurance providers will work as quickly as possible to implement this guidance in ways that limit consumer confusion and challenges. While there will likely be some hiccups in early days, we will work with the administration to swiftly address issues as they arise."

Margaret A. Murray, CEO of the Association for Community Affiliated Plans, said, "We support the administration's intent to make at-home COVID tests accessible for everyone. Nobody should forgo a needed COVID test on the basis of cost. Accordingly, ACAP-member Safety Net Health Plans will do their part to implement these regulations with all due haste."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com