Over the Counter COVID-19 Diagnostic Tests Are Required to Be Reimbursed by Your Health Care Plan

Ruth Binger

By Ruth Binger

covid testOn December 2, 2021, President Biden announced that the Departments of Labor, Treasury, and Human Resources (“Departments”) would issue guidance by January 15, 2022, to clarify that individuals who purchase Over The Counter COVID-19 Diagnostic tests (“OTC Tests”) during the public health emergency will be able to seek reimbursement from their group health plans or health insurance plans insurers (Collectively “Plans”).

On January 10, 2022, the Departments updated their guidance to generally require coverage of OTC tests, with or without a prescription or individualized clinical assessment by an attending health care provider. The Plan cannot impose cost-sharing requirements, prior authorization, or other medical management requirements.  The test needs to be for Plan participant’s personal use or for a family member enrolled under the Plan.

How to Purchase?

The Plan can provide direct coverage at the place of purchase or require a post-purchase claim for reimbursement. The Guidance strongly recommends direct coverage. The Plan can require reasonable documentation of proof of purchase with a claim for reimbursement such as attestations that the purchase was for individual use and the test was not resold or reimbursed by another source.

For What?

Only for diagnostic purposes and not for the purpose of employer-mandated tests.

OTC Cost and Number of Tests Limited?

For those OTC Tests without medical involvement, the Plan may set the limit for at least eight individual tests per 30-day period or calendar month per participant. There is no limit to tests prescribed by a health care provider. Further, if a Plan meets certain requirements, the Plan can limit the amount of reimbursement for tests from non-network pharmacies or retailers to the lesser of (1) the actual price of the test or (2) $12.

Begin and End?

Begins on or after January 15, 2022, and ends when public health emergency ends.

This new guidance and the January 15 deadline will require the Plans to move quickly to communicate the changes to the Plan participants.

Posted by Attorney Ruth Binger. Binger serves both emerging and mature businesses concentrating in corporate law, intellectual property and technology law, cybersecurity, digital media law, and labor and employment law. Her commitment to the success of small to medium-sized businesses, and her understanding of multi-faceted issues inherent in operations, are what distinguish Binger’s practice.

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