Incentivizing Insurers to Cover COVID-19 Tests

According to a statement on the website of the Centers for Medicare & Medicaid Services, most consumers with private health coverage can go online or to a pharmacy or store, buy a test, and have their health plan pay for it, either upfront or after they submit a claim. “This requirement incentivizes insurers to cover these costs up front and ensures individuals do not need an order from their health care provider to access these tests for free.” The policy took effect Jan. 15. The full details of the policy are available on the CMS website.

The government says it is “strongly incentivizing” insurers to set up networks of pharmacies and other retailers in which people with private health coverage will be able to order online or walk in and pick up at-home, over-the-counter COVID-19 tests for free rather than go through the process of having to submit claims for reimbursement. Consumers are advised to check with their plan.

What are the maximums?

If a plan has not set up a network of retailers at which consumers can obtain a test with no out-of-pocket expense, consumers will be reimbursed the amount of the cost of the test. “For example, if you buy a two-pack of tests for $34, the plan or insurer would reimburse $34.” If the plan has set up such a network from which consumers can obtain a test with no out-of-pocket expense, they can still obtain tests from other retailers outside that network. In that situation, the maximum reimbursement is only $12, so it pays to find an in-network supplier if the insurer has one.

Insurers must cover eight free over-the-counter, at-home tests per covered individual per month. Consumers may buy all eight at once each month or one at a time. However, there is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.

In addition to making the announcement, the CMS has provided FAQs that clarify the new policy.