New Rules about COVID Tests
In March of 2020, when the CARES Act was passed, most people were focused on pay protections, primarily since they included sole proprietorships, a category that covers most so-called “gig workers.” A lot of its provisions also went into effect relatively quickly. But there was another provision in that act and the associated FFCRA that might have been missed, because it wasn’t about pay and it wasn’t effective until just this past Saturday.
Under that provision - which, at the time, I suspect many people, Congress included, may have hoped would not need to become an issue - health insurers are now required to cover over-the-counter COVID-19 tests without any sort of cost share. However, it’s not as easy as going down to the local pharmacy, showing your insurance card, and getting a test for free. There are some requirements that are involved.
The first one, of course, is determining whether the pharmacy even has any tests to give out. To address that problem, the Biden Administration has ordered more tests and, at some point within the next couple of weeks, the government will launch a web site where tests can be ordered online and delivered in the U.S. Mail. They’re also supporting the establishment of more emergency rapid-testing sites in “hot spots” which have the most need.
Update 18 Jan 2022, 6 hours after posting: the web site is now live at COVIDtests.gov, but supplies are limited which means they are strictly limiting the number of tests that can be sent to any one household. However, some major pharmacy chains have indicated they will also make the tests available for little to no cost, even to the uninsured. More information can be found at the DHHS Web Site.
It’s important to note that, for those with Medicare or without any health coverage at all, the web site and community rapid-testing sites may be the only places where free tests are available. (Some pharmacies may also make them available, but there don’t appear to be any requirements that they do.)
The second requirement has to do with in-network and non-network pharmacies. While insurers are not allowed to require that members only go to in-network pharmacies, the reimbursement rate for use of out-of-network pharmacies can be as low as $12 per test. I was at my regular pharmacy the other day and they were charging $15.99 for take-home rapid tests, so it’s important to keep in mind that $12 may not cover the full cost of a test. Make sure that you’ve checked the pharmacy is in-network.
Third, there is a limit on the number of tests that must be covered. Insurers are only required to cover eight tests per 30-day period, per covered individual. This means that if a person needs to test themselves every week, they’ll be want to be careful about sharing tests with others; and people who need to test twice a week may not have any extras to share. It’s also worth noting that tests taken for employment purposes may not necessarily be covered, and that there are fraud provisions that mean that insurers can require members, among other things, to submit attestations and/or proofs of purchase.
The fourth issue that’s going on right now may be one of the most significant. The final guidance from the Biden Administration wasn’t released until January 10, which left insurers with very little time to set their systems up to cover the tests without upfront cost-sharing. This is much more of an issue than it may seem, because pharmacies verify benefits and set prices in a way that’s very different from medical providers. The systems used by pharmacies are considerably more rigid about variations and exceptions; several that I work with don’t have any mechanism for exceptions at all.
Because of the difference in the way pharmacy claims are handled, it’s very likely that most - if not all - insurance plans will need additional time to set up their systems to cover the tests without an upfront cost from the member. If plans are making good-faith and timely efforts to get the system set up, the Department of Labor will not take any action against them. What this means for consumers is that, especially at first, it may be necessary to pay for the tests and then file for reimbursement, even when using an in-network pharmacy.
Finally, it’s important to note that the new testing provisions apply to self-administered tests, usually called “at-home tests.” The PCR tests, the ones that are only administered by medical providers, are covered cost-free under another provision of the law. Right now, this isn’t particularly significant to those with health insurance, but in the future it is possible that coverage of the at-home tests and PCR tests could again become different.
The new provisions are indeed going to make it easier to test yourself for COVID-19, and in general they are fairly user-friendly. As insurers get their IT systems online, getting them will also become easier. In the meantime, though, it’s important to understand that this is such a brand-new provision, with such a short time to implement, that there are bound to be kinks in the processes. If you need to get tests, keep a close eye out for your insurer’s special instructions, and for the upcoming web site launch. They’ll be coming as quickly as the relevant organizations can get them out.
Sources:
- Associated Press with Terry Tang, Contributor. Biden Requires Home COVID Tests To Be Covered By Insurers. Insurance News Net, 10 Jan 2022.
- Mattinson, Jacob, Teal Trujillo and Judith Wethall. Are Out-of-Pocket Costs on Their Way Out? At-Home COVID-19 Testing and Expanded Preventative Healthcare for Women and Children. Employee Benefits Blog, 14 Jan 2022.
- Silva, Sean and Michael Halford. Health & Group Benefits Update: Guidance issued through FAQs on Coverage for OTC COVID-19 Tests. Milliman.com, 14 Jan 2022.
Originally posted at https://radius.stannumenterprises.com/2022/new-rules-about-covid-tests/.