Under a new policy detailed on Jan. 10 by the Biden administration, health insurers will be required to cover at-home COVID-19 tests for people insured under their plans beginning on Jan. 15. The details were announced the same day WHA issued a press release
urging the public to avoid visiting hospital emergency departments to receive COVID-19 tests.
“These issues are importantly linked,” said WHA President and CEO Eric Borgerding. “To the extent patients can access at-home COVID tests, it will help lighten the burden on hospital emergency departments and better allow hospitals to care for the high volume of patients they are now seeing, which, ultimately, is in the best interest of patients, those purchasing health insurance and our communities.” WHA’s messaging discouraging Wisconsinites from seeking COVID-19 tests in emergency departments received widespread media coverage throughout the state.
Under the new federal requirements, private health insurers will be required to cover up to eight at-home COVID-19 tests per person enrolled in their health plans. For a family of four, that means up to 32 tests. Insurers were already required to cover, with no cost sharing, COVID-19 diagnostic tests when a licensed or authorized health care provider administers or has referred a patient for such a test. Such PCR tests and rapid tests ordered or administered by a health provider will continue to be fully covered by insurance with no limit.
Insurers will have a choice in how to implement the new provisions, but the Biden administration indicates its intent is to incent insurers to set up a network of options, such as a pharmacies, retailers or online sources, where individuals can get tests without having to pay upfront. If it does establish such a network, then the plan or insurer is permitted to limit the reimbursement for tests purchased outside of its network to $12 per test. However, if the plan or insurer does not set up a process through which individuals can obtain the test in-network with no upfront costs, and instead the individual has to pay and then submit reimbursement, then the plan and insurer would have to reimburse the full cost of the test, even if the test costs more than $12.
Health insurers are working to implement these provisions. Although some insurer websites might still indicate they don’t pay for at-home tests, that should change, and enrollees should know that their tests purchased on or after Jan. 15 must be covered. The federal guidance indicates that people who buy tests should keep their receipt for reimbursement, and they should contact their insurer about the process for reimbursement.
Answers to frequently asked questions about how consumers can get at-home COVID tests for free are available here
Last year’s American Rescue Plan Act (ARPA) required state Medicaid to cover at-home COVID-19 tests. However, neither ARPA nor these new requirements apply to people on Medicare. Instead, the federal guidance indicates that up to 50 million free at-home tests are being provided to community health centers and Medicare certified health clinics for distribution at no cost to patients and community members. The guidance also indicates that Medicare Advantage plans may offer coverage and payment for at-home tests and recommends that individuals with a Medicare Advantage plan contact their plan to see if they are covering at-home tests.