New Guidance Requires Health Care Plans to Pay for Over-the Counter COVID-19 Tests Without a Doctor’s Order

On January 10, 2022, the Departments of Labor, Health and Human Services, and Treasury (collectively, the “Departments”) issued additional guidance regarding required health plan coverage of over-the-counter (“OTC”) COVID-19 tests. (“FAQs About the Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation” (the “FAQs”).)

Required Coverage of OTC COVID-19 Tests

On and after January 15, 2022, fully-insured and self-insured health care plans:  

• Are required to cover FDA-approved OTC COVID-19 tests without imposing any cost-sharing on the plan participant with or without an order or independent assessment from a health care professional.
• Cannot limit coverage of OTC Covid-19 tests to tests that are provided through preferred pharmacies. The FAQs provide a safe harbor that allows a health care plan to limit test coverage to both its pharmacy network and to a direct-to-consumer shipping program if statutory criteria are satisfied. Under the safe harbor plans must also cover OTC COVID-19 tests at non-preferred pharmacies or other retailers at no less than the purchase price or $12, whichever is lower.
• Can limit the number of OTC Covid-19 tests covered with no cost sharing to no fewer than eight (8) per plan participant per 30-day period or calendar month. This limit does not apply to COVID-19 tests with an order or assessment from a health care professional.
• Are permitted to address suspected fraud and abuse regarding OTC COVID-19 coverage. 

The FAQs also provide guidance regarding health plan payment for and reimbursement of OTC COVID-19 tests.

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For more information and compliance assistance please contact Brandie Barrows at bbarrows@taylorenglish.com.