Insurers Must Cover At-Home COVID-19 Tests Starting Jan. 15 Under New CMS Directive

January 11, 2022

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Source: Fierce Healthcare, by Robert King

Insurers must cover at least eight at-home COVID-19 tests per covered individual starting on Saturday, per a new directive from the Biden Administration.

The frequently-asked questions document released by the Centers for Medicare & Medicaid Services (CMS) is an effort to improve access to at-home tests, which have been in short supply in recent weeks amid a surge of the virus fueled by the omicron variant. The administration, which announced it would install the requirement last month, also wants insurers to take steps to ensure consumers can get the tests at the pharmacy counter with no out-of-pocket costs.

“Testing is critically important to help reduce the spread of COVID-19, as well as to quickly diagnose COVID-19 so that it can be effectively treated,” said CMS Director Chiquita Brooks-LaSure in a statement. “Today’s action further removes financial barriers and expands access to COVID-19 tests for millions of people.”

CMS’ guidance applies to insurers and group health plans, requiring them to cover 8 free over-the-counter at-home tests per covered individual a month.

“That means a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month,” a release on the guidance said. “There is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a healthcare provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.”

Over-the-counter test purchases also will be covered without any cost-sharing requirements such as deductibles or co-pays.

CMS is also hoping to incentivize insurers and group health plans to set up programs that would enable consumers to get tests at the pharmacy or point-of-sale without any out-of-pocket costs.

“Insurers and plans would cover the costs upfront, eliminating the need for consumers to submit a claim for reimbursement,” the agency said in the release.

If a plan or insurer makes the tests available via a preferred pharmacy or retailer, they still must reimburse the tests purchased by consumers outside of that network at up to $12 per individual or the cost of the test if it is below $12.

“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,” the agency added.

State Medicaid programs and the Children’s Health Insurance Program are already required to cover at-home tests.

However, some stakeholders are worried that the guidance doesn’t address major problems facing testing access, which can include shortages.

“The guidance issued today fails to address the enormous barriers: significant shipping delays, sold-out pharmacies and retailers and the early signs of price-gouging,” said Ceci Connolly, president and CEO of the Alliance of Community Health Plans, in a statement.

Blue Cross Blue Shield Association also was concerned about the lack of action in alleviating shortages.

“We are concerned that the policy does not solve for the limited supply of tests in the country and could cause additional consumer friction as insurers stand up a program in just four days’ time,” said President and CEO Kim Keck in a statement.

The administration is also working to send 500 million rapid tests in the coming weeks to every American.

At the onset of the pandemic, many major insurers agreed to cover the cost of COVID-19 tests. However, several of those coverage decisions were eventually reversed as the pandemic wore on.

 

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