Covid-19 At-Home Test Mandatory Reimbursement

New regulations, effective January 15, 2022, require group health plans and health insurance issuers to cover up to 8 at-home Covid tests per covered individual per month. The rules require group health plans and health insurance issuers to cover rapid at-home COVID-19 tests with:

• No cost-sharing applied
• No prior authorization required
• No medical management requirements.

Here are some of the most commonly asked questions and answers regarding the new requirement.

How do group health plans or health insurance issuers reimburse covered individuals who purchase rapid at-home COVID-19 tests?

The regulations incentivize group health plans and health insurance issuers to create relationships with pharmacies and drug stores (CVS, Walgreens, or a local pharmacy chain) to allow covered individuals to purchase tests at their nearest pharmacy and bill their health plan directly. This allows the covered individual to purchase the test without any up-front payment or needing to submit a reimbursement to their group health plan or health insurance issuer.

How many at-home tests is a group health plan or health insurance policy required to cover per covered individual?

The regulations require group health plans and health insurance issuers to cover up to 8 rapid at-home tests per covered individual per month. This means that a family of 4 enrolled on a group health plan or health insurance policy could get up to 32 rapid at-home tests covered.

Are there limits placed on the dollar amount group health plans and insurers must reimburse a covered individual for a rapid at-home COVID-19 tests?

Yes. The new regulations place limits on the dollar amount that a group health plan or health insurance issuer must reimburse covered individuals for rapid at-home tests. The dollar limits vary based upon whether the group health plan or health insurance issuer has structured a program where covered individuals can purchase tests at pharmacies with no up-front payment:

• If the group health plan or health insurance issuer has set up a preferred pharmacy network, then the health plan or health insurance issuer must still reimburse plan participants for out-of-network at-home tests up to $12 per test per covered individual. The $12 per test limit matches a full reimbursement for the most widely available $24 packs of two at-home tests available at most commercial pharmacies.
• If the group health plan or health insurance issuer has not set up a preferred pharmacy reimbursement network, then the group health plan or health insurance issuer must reimburse the participant the full cost of the test. For example, if a covered individual pays $34 for two tests, and the group health plan does not have a pharmacy network, the group health plan must reimburse the covered individual the $34 they paid for the two tests. The reimbursement is not limited to $12 per test.
• It is important note that the term “network” means pharmacy locations where members can purchase tests for no-upfront costs. “Out-of-network” means an at-home test where the participant pays up front and submits a reimbursement to their group health plan or health insurance issuer. The terms do not mean a traditional PPO network. The regulations apply to all group health plans and health insurance issuers regardless of whether a traditional PPO network is used.