By: TAHP | Tuesday, January 11, 2022

by Alicia Pierce, Jamie Dudensing

Starting January 15, individuals with private health insurance will have coverage for up to eight at-home COVID tests per month, per covered family member.

Guidelines surrounding the requirement were released by the Biden Administration yesterday. Health plans may pay for these tests up front or reimburse individuals through a claims process, but the administration encouraged establishing a process that does not require consumers to initially pay for the tests. Tests for diagnostics purposes will be covered but tests used for surveillance purposes, including employer required checks, are not part of the order.

Requirements under this policy are effective for tests purchased on or after January 15, 2022, but issuers “may” reimburse for tests purchased before January 15.

If health plans provide direct coverage of at-home COVID-19 tests through both its pharmacy network and a direct-to-consumer shipping program, health plans may limit the amount of reimbursement to $12 per test. Price limits for reimbursement are necessary as patterns of price gouging have been seen throughout the pandemic. In Texas, the problem is especially egregious from freestanding ERs, where reports of on-site tests of more than $10,000 have been common.

Individuals with private insurance seeking covered at-home tests should:

• Look for guidance from their health plans
• Save any receipts and proof of purchase
• Know out-of-networks reimbursements may be capped at $12 per test

Since early in the pandemic, health plans have covered out-of-home, diagnostic testing without any cost to members. The new guidance from the federal government does not change that.

Individuals without private insurance also have options. For Medicare members, the federal government is providing up to 50 million free, at-home tests to community health centers and Medicare-certified health clinics for distribution at no cost to patients and community members. People enrolled in a Medicare Advantage plan should check with their plan to see if their plan offers coverage and payment for at-home over-the-counter COVID-19 tests.

State Medicaid and Children’s Health Insurance Program (CHIP) plans are currently required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. Members may obtain at-home test kits from a Medicaid-enrolled retail pharmacy with or without a prescription from a prescribing provider and are limited to four tests per calendar month.

The guidance follows President Biden’s December announcement on federal actions to protect Americans against COVID-19. Please see HHS’ press release for more details and FAQs for consumers.