New Guidance Requires Health Care Plans to Pay for Over-the Counter COVID-19 Tests Without a Doctor’s Order

Information Current as of January 11, 2022

On January 10, 2022, the Departments of Labor, Health and Human Services, and Treasury (collectively, the “Departments”) issued additional guidance regarding required health plan coverage of over-the-counter (“OTC”) COVID-19 tests.[1]

Required Coverage of OTC COVID-19 Tests

On and after January 15, 2022, fully-insured and self-insured health care plans: 

  • Are required to cover FDA-approved OTC COVID-19 tests without imposing any cost-sharing on the plan participant with or without an order or independent assessment from a health care professional.
  • Cannot limit coverage of OTC COVID-19 tests to tests that are provided through preferred pharmacies. The FAQs provide a safe harbor that allows a health care plan to limit test coverage to both its pharmacy network and to a direct-to-consumer shipping program if statutory criteria are satisfied. Under the safe harbor plans must also cover OTC COVID-19 tests at non-preferred pharmacies or other retailers at no less than the purchase price or $12, whichever is lower.
  • Can limit the number of OTC Covid-19 tests covered with no cost sharing to no fewer than eight (8) per plan participant per 30-day period or calendar month. This limit does not apply to COVID-19 tests with an order or assessment from a health care professional.
  • Are permitted to address suspected fraud and abuse regarding OTC COVID-19 coverage.

The FAQs also provide guidance regarding health plan payment for and reimbursement of OTC COVID-19 tests.

[1] “FAQs About the Affordable Care Act Implementation Part 51, Families First Coronavirus Response Act and Coronavirus Aid, Relief, and Economic Security Act Implementation” (the “FAQs”).

‹ Alerts