On January 10, 2022, the Departments of Health and Human Services, Labor and Treasury issued guidance addressing a group health plan’s obligation to cover the cost of over-the-counter, at-home COVID-19 tests starting January 15, 2022. The new coverage requirement means that enrolled individuals can go online or to a pharmacy and buy an over-the-counter FDA-approved COVID-19 diagnostic test and either have it paid for up front by their health plan or be reimbursed by submitting a claim without any cost-sharing requirements (such as deductibles, co-payments or co-insurance). The guidance provides that beginning January 15, 2022 through the end of the declared public health emergency, plans must cover at least eight (8) over-the-counter at-home tests per enrolled individual per 30-day (or calendar-month) period without an assessment or provider involvement. This does not affect the obligation to provide coverage for COVID-19 tests with a provider’s involvement or prescription.
The table below provides more details about the required coverage of at-home COVID-19 tests as well as a snapshot of the required coverage of other COVID-19-related testing, vaccines and treatment.
Required Coverage of COVID-19 Related Benefits as of January 15, 2022 |
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COVID-19-Related Benefit | Are Group Health Plans* Required to Cover this Benefit? | Is the Benefit Required to be Provided without Cost-Sharing, Prior Authorization or Other Medical Management Requirements? | Comments |
COVID-19 Vaccinations (including Boosters) | Yes – Plans must cover any FDA-authorized or approved COVID-19 vaccine immediately upon approval or authorization | Yes, regardless of whether it is administered by an in-network or out-of-network provider |
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COVID-19 Testing
and Related Diagnostic Services (other than OTC Tests) |
Yes (for the duration of the public health emergency) –
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Yes – Plans cannot use medical-screening criteria to impose cost-sharing
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COVID-19 FDA-Approved Over-the-Counter At-Home Tests (“OTC Tests”) | Yes (as of 1/15/22) –
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Yes –
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COVID-19 Treatment | No – there is no federal requirement to cover specific items and services needed to treat complications due to COVID-19. | No – the Plan’s rules related to cost-sharing, prior authorization and other medical management are permitted (although some Plans waived cost sharing, at least prior to the availability of the COVID-19 vaccines) | HIPAA’s prohibition against discrimination based on a health factor would prohibit denying eligibility for benefits or coverage based on whether an individual obtains a COVID-19 vaccination |
* Different rules may apply to group health plans that are grandfathered under the Affordable Care Act (ACA) or that are retiree-only or provide only excepted benefits.