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DOL addresses reimbursement for OTC COVID-19 tests

Authored by Bukaty Companies on January 11, 2022

Reimbursement not required for employment-purposes testing

Yesterday afternoon, the Department of Labor (DOL) released a set of frequently asked questions (FAQs) addressing how individuals who purchase over-the-counter (OTC) COVID-19 diagnostic tests that are approved by the Food and Drug Administration can be reimbursed from their health plan.

The six FAQs clarify that OTC COVID-19 tests purchased without an order or individual clinical assessment by a health care provider are subject to limited or no cost-sharing requirements, prior authorization or other medical management requirements. The guidance allows for after-purchase reimbursement, but the DOL encourages plans and issuers to provide direct coverage to avoid upfront payment.

The guidance incentivizes health plans to allow consumers to purchase COVID-19 tests without upfront payment through a network pharmacy and direct-to-consumer shipping programs, but confirms that OTC COVID-19 tests purchased from other pharmacies and retailers are eligible for reimbursement not to exceed $12 per test. Self-funded health plans with a carveout pharmacy benefit manager (PBM) will need to work with their PBM to determine how the advance payment or reimbursement process will work.

Health plans can limit the number and frequency of OTC COVID-19 tests covered without cost sharing per participant, beneficiary or enrollee to no less than eight tests per 30-day period (or calendar month). There are no limits if a COVID-19 test is ordered by a health care provider.

Health plans are permitted to address suspected fraud and abuse by requiring an attestation that the tests are “for personal use, not for employment purposes, has not been (and will not be) reimbursed by another source and is not for resale.” This sample language presumes that if the OSHA emergency temporary standard (ETS) weekly testing requirement goes into effect on February 9, the cost of weekly COVID-19 testing is the employee’s responsibility not the health plan.*

Health plans are encouraged to provide helpful information to support consumers seeking OTC COVID-19 testing and are required to communicate how to submit a claim for reimbursement, including electronic and paper filing options.

The new coverage and reimbursement requirements are in effect for OTC COVID-19 tests purchased on or after January 15, 2022, and during the public health emergency.

As carriers release their policies regarding the reimbursement process, Bukaty Companies will release that information to our respective client audiences.

For additional information, contact your Bukaty benefits consultant at 913.345.0440.

*Once released, Bukaty Companies will report on the Supreme Court’s decision regarding the Biden administration’s vaccine masking and testing requirement for employers with 100 or more employees.


Blog Category: Benefits, Compliance