Under the Families First Coronavirus Response Act (FFCRA) and the Coronavirus Aid, Relief, and Economic Security (Cares) Act, two covid-19 emergency measures passed by Congress, companies Private insurance providers should generally cover COVID-19 tests ordered by providers, typically those performed on-site, such as in clinical or emergent settings (providers can also seek federal reimbursement for testing uninsured patients). This broad coverage requirement has been in place since the early days of the pandemic, with the only exceptions being that private insurers do not have to reimburse for tests performed for public health surveillance or workplace requirements.
The Biden administration announced on December 2, 2021 (followed by detailed guidance published on January 10, 2022) that private insurers will also need to begin covering the cost of purchased rapid home COVID-19 tests. no prescription counter as of January 15, 2022.
According to the new guidance, private insurance companies must cover up to 8 fda-authorized rapid tests per member per month. this averages around 2 rapid tests per week for those eligible. this policy applies to all private health insurers and does not apply to medicare managed care or medicare advantage plans. private insurers are required to provide a coverage mechanism for their affiliates, although some are just beginning to implement these processes. In addition to offering reimbursement for tests purchased out of pocket, the guide also encourages insurers to establish “direct coverage” options. In these arrangements, members can buy rapid tests at home without paying anything up front or going through a complicated reimbursement process if the test is obtained through a preferred network of pharmacies or retailers, or through a mail-order option. . Enrollees in plans with direct coverage options can also request reimbursement for tests purchased from non-preferred retailers, but the guidance allows insurers to limit reimbursement to $12 per test. If the insurance company does not have a direct coverage option, it must reimburse the member for the full cost of the test. The goals of these provisions are to simplify coverage for consumers (through the direct coverage option) and mitigate the effects of inflation on test prices (through the cap). Insurers have an incentive to set up direct coverage options because the $12 reimbursement limit can also help limit your costs. If many or most insurers establish these programs and implement the $12 limit, it could also affect the price of tests as retailers and manufacturers target the reimbursement target.
To assess how insurers are beginning to implement this policy, from a consumer perspective, we reviewed the publicly available rapid covid home testing coverage and reimbursement policies for the 13 private insurers with at least 1 million insurers. fully insured members in their usa uu. subsidiaries (Table 1) between January 18, 2022 and January 20, 2022. These private insurers cover about 6 out of 10 people in the fully insured commercial market. Most of these parent companies have the same coverage and reimbursement policy across all of their subsidiaries, but when that was not the case, we include the policy for their largest subsidiary.
At this time, about half of the insurers reviewed are implementing their test coverage policy using reimbursement only.
- 7 insurers (Anthem, Blue Cross Blue Shield of Michigan, Blue Shield of California, Care First, Cigna, CVS Group/Aetna, and Kaiser Permanente) currently rely on reimbursement practices (i.e. they do not have a direct coverage option) and have varied reimbursement policies. (anthem also has “a limited number of home diagnostic test kits available for certain members to order online”)
- 4 of the 7 insurers (blue cross blue shield of michigan, blue shield of california, care first, cigna) require receipts and a form is mailed (typically one submission per receipt per member). one insurer (cigna) also offers a fax option. none of these seem to provide email or online shipping. one insurer (cvs group/aetna) states that it will reimburse members but does not describe the reimbursement procedure.
- 2 insurers offer an online option to submit reimbursement forms (anthem and kaiser Permanente).
- 3 insurers also require that the universal product code (UPC) or barcode information on the product be mailed with the receipt.
- 6 of the top 13 insurers have a direct coverage option right now. Blue Cross Blue Shield of North Carolina, Centene/Ambetter, Health Care Service Corporation, Guidewell (Florida Blue), Humana, and United Health Group Commercial Plan members can purchase rapid tests at a network or preferred pharmacy and will not have to pay anything in advance. Kaiser Permanente says they will have direct coverage in the future, but they don’t provide this option yet.
- 5 of the 6 insurers with a direct coverage option (Blue Cross Blue Shield of North Carolina, Centene/Ambetter, Guidewell (Florida Blue), Humana, and United Health Group) also explain how members can apply for reimbursement costs that have been faced with non-preferred network retailers, usually by mail order and one that also offers an online option. another insurer (health care services corporation) does not provide any specific information and instead directs members to contact their health plan administrator.
- Of the 6 insurers with the direct coverage option, 5 specify that claims outside the preferred network are subject to a maximum reimbursement of $12 per test. These insurers include: Blue Cross Blue Shield of North Carolina, Centene/Ambetter, Guidewell (Florida Blue), Health Care Service Corporation, and United Health Group
- A (human) insurer with direct coverage did not indicate a maximum reimbursement amount.
The remaining half of the major insurers had a direct coverage option set up at the time of the review.
See also: Mexico Travel Insurance
Enrollees in plans with a direct coverage option may be reimbursed limited to $12 per test if a test is purchased outside of this option.
The success of this policy depends on two main factors: the availability of evidence and the ability of members to navigate the process of reimbursement or direct coverage. As we’ve written elsewhere, despite recent efforts to increase the supply of tests, it can still be a challenge to find a home COVID test online and in pharmacies. if supply remains limited and tests are not widely available, a direct coverage or reimbursement mechanism does little to improve access.
People who find rapid tests may also have difficulty navigating the process for reimbursement or direct coverage. As our analysis shows, in the early days of implementation, insurers have different coverage policies, including whether they have a direct coverage option or require members to apply for reimbursement, and when members apply for reimbursement, either online or offline. by mail or fax. some of these processes will inevitably be more consumer-friendly than others and will either make coverage easier or put up additional barriers. even if the cost is eventually reimbursed, many families could face financial barriers if their insurer requires payment up front. many people don’t have easy access to printers or fax machines, required by some insurers for reimbursement, which will likely mean some claims are never filed. additionally, as noted, this policy applies only to those with private insurance, so those without insurance or those with other coverage will have to navigate different options, including requesting tests directly from the federal government (with a limit currently four per household). still, this new policy is a step toward improving the accessibility and affordability of covid-19 testing in the us. uu.