As of January 15, private and group health plans must cover the cost of over-the-country Covid-19 diagnostic tests that have been authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA). Insurance companies and health plans are required to cover 8 free over-the-counter at-home tests per covered individual per month.
However, there already seems to be some confusion among some insurers about this arrangement as some media outlets are reporting.
Here’s what the government is advising.
When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers who are outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12).
Over-the-counter test purchases will be covered in the commercial market without the need for a healthcare provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments or coinsurance, prior authorization, or other medical management requirements.
State Medicaid and Children’s Health Insurance Program (CHIP) programs are required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. Last year, the government issued guidance explaining that state Medicaid and Children’s Health Insurance Program (CHIP) programs must cover all types of FDA-authorized COVID-19 tests without cost sharing under CMS’s interpretation of the American Rescue Plan Act of 2019.
Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests, with no beneficiary cost sharing when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional.
In addition, HHS 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.
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For more information regarding coverage and billing, please call 305-358-4500 or email [email protected].