This week, the Biden-Harris Administration announced that insurance companies and group health plans must cover the cost of over-the-counter, at-home COVID-19 tests, so people with private health coverage can get them for free starting January 15. Insurance companies and health plans must cover eight free over-the-counter at-home tests per individual per month.
The new coverage mandate 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 upfront by their health plan or get reimbursed for the cost by submitting a claim. This requirement incentivizes insurers to cover these costs upfront and ensures individuals do not need an order from their health care provider to access these tests for free.
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.
As part of the requirement, the Administration is incentivizing insurers and group health plans to set up programs that allow people to get the over-the-counter tests directly through preferred pharmacies, retailers or other entities with no out-of-pocket costs.
Insurers and plans would cover the costs upfront, eliminating the need for consumers to submit a claim for reimbursement. 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). For example, if an individual has a plan that offers direct coverage through their preferred pharmacy but that individual instead purchases tests through an online retailer, the plan is still required to reimburse them up to $12 per individual test. Consumers can find out more information from their plan about how their plan or insurer will cover over-the-counter tests.