Employer-Sponsored Health Plans Must Cover or Reimburse Costs of Over-the-Counter COVID Testing beginning January 15, 2022

Alert

Following the increased availability of diagnostic tests for COVID-19 that are self-administered at home or without the involvement of a health care professional (“self-tests”), employer-sponsored group health plans and health insurers are now required to provide reimbursement to plan participants, or to provide coverage to plan participants, without cost sharing requirements (such as copayments), prior authorization, or other medical management requirements, for over-the-counter (“OTC”) COVID-19 diagnostic self-tests beginning January 15, 2022. 

This guidance was issued in FAQ format on January 10, 2022, by the Departments of Labor, Health and Human Services and the Treasury under the Families First Coronavirus Response Act (“FFCRA”), the Coronavirus Aid, Relief, and Economic Security Act (“CARES Act”), and the Affordable Care Act.[1] 

The guidance is more nuanced than employers likely expect and requires quick action with your plan’s insurer or third-party administrator, so please contact us when diving in to the details. 

Here are the key takeaways:

  • Group health plans and health insurers are required to provide coverage or reimbursement for OTC COVID-19 testing that is primarily intended for individualized diagnosis or treatment of COVID-19. This guidance reiterates that a group health plan is not required to provide coverage or reimbursement for COVID-19 testing that is for employment purposes.
  • If a group health plan or insurer provides direct coverage for OTC COVID-19 self-tests, this coverage cannot be limited to only tests provided through preferred pharmacies or other retailers and the plan or insurer must take reasonable steps to ensure that participants have “adequate access” to OTC COVID-19 self-tests through an “adequate number” of retail locations (including both in-person and online locations).
  • However, a group health plan or insurer may limit reimbursement for OTC COVID-19 self-tests from non-preferred pharmacies or other retailers to no less than the actual price or $12 per test, whichever is lower.
  • A group health plan or insurer may limit the number of OTC COVID-19 self-tests that are covered or reimbursed without cost-sharing to no fewer than eight (8) tests per participant per 30-day period (or per calendar month).
  • When providing for reimbursement of OTC COVID-19 testing, a group health plan or insurer may require reasonable documentation of proof of purchase.

Note that this guidance also contains FAQs about coverage of other preventive services, but we have not addressed those in this summary.

Please contact any member of the Honigman Employee Benefits practice with questions about this or other guidance issued under FFCRA, the CARES Act, the Affordable Care Act, and/or the Employee Retirement Income Security Act of 1974 (ERISA).  

[1] See FAQs About Affordable Care Act Implementation Part 51, available at https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf, and issued January 10, 2022.

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