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January 12, 2022
On January 10, 2022, the Departments of Labor (DOL), Health and Human Services (HHS), and Treasury (“The Departments”) released Frequently Asked Questions (FAQ) Part 51, in response to the Biden Administration’s directive to issue guidance requiring group health care plans and insurers to provide coverage of over-the-counter (OTC) in-home COVID-19 diagnostic tests. Beginning January 15, 2022, group health care plans, including fully-insured and self-insured plans, and individual insurance policies will be required to cover the cost of OTC in-home COVID-19 testing without any cost sharing or requirements that participants obtain authorization for the tests.
The FAQs build upon the requirements of the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) for coverage of COVID-19 diagnostic testing, and the Affordable Care Act (ACA) preventive care requirements. In addition, the FAQs include guidance on coverage of preventive services.
The guidance is applicable to self-insured and fully insured group health care plans, including grandfathered health plans (“plans”).
Note: the guidance specifically states that plans and issuers are not required to provide coverage of testing (including an OTC COVID-19 test) that is for employment purposes.
Plans may not restrict reimbursements to OTC tests provided only by certain pharmacies or other retailers. However, plans may limit reimbursements for tests purchased from non-network pharmacies or other retailers to $12 per test, or the actual price, whichever is lower.
The Departments note that this safe harbor applies only with respect to the coverage of OTC COVID-19 tests that are administered without a provider’s involvement or prescription. Plans and issuers must continue to provide coverage for COVID-19 tests that are administered with a provider’s involvement or prescription, as required by section 6001 of the FFCRA and the Departments’ guidance, even when relying on this safe harbor.
Plans may take reasonable steps to ensure that the covered test is purchased for the individual’s own use including an attestation by the participant that the test is for the participant’s (or beneficiary’s or enrollee’s) own use as long as these steps do not create “significant barriers” for these individuals to obtain the test. Plans may require reasonable documentation as proof of purchase with an individual’s claim for reimbursement.
The guidance encourages plans (and thus, plan sponsors) to educate and support participants seeking OTC and provider involved COVID-19 testing including providing information:
Employers/plan sponsors must ensure the plan is prepared to provide reimbursements to participants for OTC COVID-19 testing, or that the plan will be able to reimburse the sellers of test kits directly. This will require working with your insurance carrier or third-party administrator (TPA). The carriers and TPAs are currently reviewing the guidance and working to establish their policies. We will share any updates we receive from your carrier or TPA.
The Departments’ FAQ Part 51 also includes new guidance for the coverage of preventive colonoscopies, and clarifications on coverage for FDA-approved contraceptive products. The full FAQ may be accessed here: opens in a new windowhttps://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-employers-and-advisers/aca-implementation-faqs
The views and opinions expressed within are those of the author(s) and do not necessarily reflect the official policy or position of Parker, Smith & Feek. While every effort has been taken in compiling this information to ensure that its contents are totally accurate, neither the publisher nor the author can accept liability for any inaccuracies or changed circumstances of any information herein or for the consequences of any reliance placed upon it.