The Departments of Labor, Health and Human Services, and the Treasury have issued Affordable Care Act FAQs Part 52 on the coverage of over-the-counter (OTC) COVID-19 tests authorized by the Food and Drug Administration (FDA). The new guidance provides flexibility for group health plans and issuers in how they meet certain direct coverage requirements, effective February 4, 2022. The FAQs also address how the requirements interact with account-based plans, such as flexible spending accounts (FSAs), health reimbursement arrangements (HRAs) and health savings accounts (HSAs).
On January 10, 2022, the Departments issued FAQs Part 51, which provided that group health plans and health insurance issuers must cover at least eight free OTC COVID-19 tests per person per month purchased on or after January 15, 2022, and throughout the public health emergency — without cost sharing, prior authorization or other medical management requirements. These include those tests purchased without a prescription or individualized clinical assessment from a healthcare provider.1
Employees enrolled in group health plans can buy an OTC COVID-19 test online or at a pharmacy or store and either get the test paid for at the point of sale by their health plan (“direct coverage”) or pay for the test upfront and then get reimbursed by submitting a claim to their health plan.
The Part 52 FAQs clarify the direct coverage program safe harbor and modify some of the previous guidance, as discussed below.
Under the direct coverage program, the plan or issuer sets up a network of preferred pharmacies or retailers (including the direct-to-consumer shipping program) where plan participants can buy their OTC COVID-19 tests with no upfront out-of-pocket costs or need to request reimbursements. Plans and issuers may limit reimbursement of tests purchased outside of that network to $12 (or the cost of the test, if lower).
The recent guidance clarifies the following issues related to the direct coverage program safe harbor:
1 For more information on FAQs Part 51, see “Departments issue FAQs on coverage of over-the-counter COVID-19 tests,” Insider, January 2022.
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Insider February 2022 | .1 MB |