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
|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||
and Related Diagnostic Services
(other than OTC Tests)
|Yes (for the duration of the public health emergency) –
||Yes – Plans cannot use medical-screening criteria to impose cost-sharing
|COVID-19 FDA-Approved Over-the-Counter At-Home Tests (“OTC Tests”)||Yes (as of 1/15/22) –
|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.
The material contained in this communication is informational, general in nature and does not constitute legal advice. The material contained in this communication should not be relied upon or used without consulting a lawyer to consider your specific circumstances. This communication was published on the date specified and may not include any changes in the topics, laws, rules or regulations covered. Receipt of this communication does not establish an attorney-client relationship. In some jurisdictions, this communication may be considered attorney advertising.