COVID-19 Home Test Cost Must be Covered by Insurance Companies, Group Health Plans

The cost of over-the-counter, at-home COVID-19 test kits will be covered by insurance companies and group health plans starting January 15, 2022, the date set by the Biden administration by which payers must cover these costs up front, according to a statement from the Centers for Medicare and Medicaid Services (CMS).

Most consumers with private coverage will be able to go online, to a pharmacy or other retail store, buy a test and have it paid for up front by their health plan or get reimbursed after submitting a claim.

The test kits must be authorized, cleared, or approved by the US Food and Drug Administration and plans must cover 8 tests per month per individual. A prescription from a physician will not be required and a purchase will not be subject to any cost-sharing requirements such as deductibles, co-payments or coinsurance, prior authorization, or other medical management requirements.

There is no limit to the number of tests covered if ordered or administrated by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.

“This is all part of our overall strategy to ramp-up access to easy-to-use, at-home tests at no cost,” said US Health and Human Services (HHS) Secretary Xavier Becerra, in the CMS statement. “Since we took office, we have more than tripled the number of sites where people can get COVID-19 tests for free, and we’re also purchasing half a billion at-home, rapid tests to send for free to Americans who need them.”

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 outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12). For example, if an individual has a plan that offers direct coverage through their preferred pharmacy, but that individual instead purchases tests through an online retailer, the plan is still required to reimburse them up to $12 per individual test.

State Medicaid and Children’s Health Insurance Program (CHIP) programs are currently required to cover FDA-authorized at-home COVID-19 tests without cost-sharing.

In 2021, the Biden Administration issued guidance explaining that State Medicaid and Children’s Health Insurance Program 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.

The US HHS is providing up to 50 million free, at-home tests to community health centers and Medicare-certified rural health clinics for distribution at no cost to patients and community members. The program is intended to ensure COVID-19 tests are made available to populations and settings in need of testing.