CMS: Insurance Companies Required to Cover At Home COVID-19 Tests

CMS NEWS
FOR IMMEDIATE RELEASE

January 10, 2022

Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries

Biden-Harris Administration Requires Insurance Companies and Group Health Plans to
Cover the Cost of At-Home COVID-19 Tests, Increasing Access to Free Tests

As part of its ongoing efforts across many channels to expand Americans’ access to free testing,
the Biden-Harris Administration is requiring insurance companies and group health plans to
cover the cost of over-the-counter, at-home COVID-19 tests, so people with private health
coverage can get them for free starting January 15th. The new coverage requirement means that
most consumers with private health coverage can go online or to a pharmacy or store, buy a test,
and either get it paid for upfront by their health plan, or get reimbursed for the cost by
submitting a claim to their plan. 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.

Beginning January 15, 2022, individuals with private health insurance coverage or covered by a
group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized,
cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those
test costs covered by their plan or insurance. Insurance companies and health plans are required
to cover 8 free over-the-counter at-home tests per covered individual per month. That means a
family of four, all on the same plan, would be able to get up to 32 of these tests covered by their
health plan per month. 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.

“Under President Biden’s leadership, we are requiring insurers and group health plans to make
tests free for millions of Americans. This is all part of our overall strategy to ramp up access to
easy-to-use, at-home tests at no cost,” said HHS Secretary Xavier Becerra. “Since we took
office, we have more than tripled the number of sites where people can get COVID-19 tests for
free, and we’re also purchasing half a billion at-home, rapid tests to send for free to Americans
who need them. By requiring private health plans to cover people’s at-home tests, we are further
expanding Americans’ ability to get tests for free when they need them.”

Over-the-counter test purchases will be covered in the commercial market without the need for a
health care provider’s order or individualized clinical assessment, and without any cost-sharing
requirements such as deductibles, co-payments or coinsurance, prior authorization, or other
medical management requirements.

As part of the requirement, the Administration is incentivizing insurers and group health plans to
set up programs that allow people to get the over-the-counter tests directly through preferred
pharmacies, retailers or other entities with no out-of-pocket costs. Insurers and plans would
cover the costs upfront, eliminating the need for consumers to submit a claim for reimbursement.
When plans and insurers make tests available for upfront coverage through preferred pharmacies
or retailers, they are still required to reimburse tests purchased by consumers outside of that
network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12). For
example, if an individual has a plan that offers direct coverage through their preferred pharmacy
but that individual instead purchases tests through an online retailer, the plan is still required to
reimburse them up to $12 per individual test. Consumers can find out more information from
their plan about how their plan or insurer will cover over-the-counter tests.

“Testing is critically important to help reduce the spread of COVID-19, as well as to quickly
diagnose COVID-19 so that it can be effectively treated. Today’s action further removes
financial barriers and expands access to COVID-19 tests for millions of people,” said CMS
Administrator Chiquita Brooks-LaSure.

State Medicaid and Children’s Health Insurance Program (CHIP) programs are currently
required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. In 2021, the
Biden-Harris Administration issued guidance explaining that State Medicaid and Children’s
Health Insurance Program (CHIP) programs must cover all types of FDA-authorized COVID-19
tests without cost-sharing under CMS’s interpretation of the American Rescue Plan Act of 2019
(ARP). Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR
and antigen tests, with no beneficiary cost-sharing when the test is ordered by a physician, nonphysician practitioner, pharmacist, or other authorized health care professional. People enrolled
in a Medicare Advantage plan should check with their plan to see if their plan offers coverage
and payment for at-home over-the-counter COVID-19 tests.

This effort is in addition to a number of actions the Biden Administration is taking to expand
access to testing for all Americans. The U.S. Department of Health and Human Services (HHS)
is providing up to 50 million free, at-home tests to community health centers and Medicare-certified health clinics for distribution at no cost to patients and community members. The program is intended to ensure COVID-19 tests are made available to populations and settings in need of testing. HHS also has established more than 10,000 free community-based pharmacy testing sites around the country. To respond to the Omicron surge, HHS and FEMA are creating surge testing sites in states across the nation.

For more information, please see these Frequently Asked Questions,http://For more information, please see these Frequently Asked Questions, https://www.cms.gov/files/document/11022-faqs-otc-testing-guidance.pdf


For additional details on the requirements, visit https://www.dol.gov/sites/dolgov/files/EBSA/aboutebsa/our-activities/resource-center/faqs/aca-part-51.pdf

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