The recent regulation that provides that the cost of over-the-counter-at-home tests be covered by health insurance providers came as a surprise. Our provider, Priority Health, is still working out the details for how this will be implemented for NMC and other employers Priority serves. The guidance we have at this time is “please advise members to keep a copy of their receipt and UPC code for any purchases of FDA approved at home COVID19 tests purchased from 1/15 on.” We have been informed that Priority is working on a point-of-sale solution in order to provide us a better customer experience.
We (HR) will provide updates to you as the situation progresses and information becomes available. Thank you!
AVP of Human Resources
1701 East Front Street, Traverse City, MI 49686
New regulations introduced for access to coverage on over-the-counter COVID-19 tests for Commercial Group and Individual Market members.
To expand Americans’ access to COVID-19 testing, new regulations were introduced by the Biden-Harris Administration this week. 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 (FDA approved) will be able to have those test costs covered 100% by their plan or insurance as part of the Families First Coronavirus Response Act, as long as the emergency order remains in place.
Important to Note: The new regulations do not solve the nationwide shortage of COVID tests and the strain on the healthcare system, including pharmacies.
What is covered under the regulations?
- Insurance companies and health plans are required to cover at no cost to the member 8 individual over-the-counter at-home tests per covered individual within a 30-day period without a prescription from a health care professional. This means a family of four, all on the same plan, can purchase up to 32 of these tests covered 100% by their health plan per month.
- COVID testing ordered by a health care professional when the test is medically necessary to diagnose and treat a patient’s symptoms continues to be covered 100%, with no member cost sharing applied and no limit to the number of tests.
- Workplace mandated testing is not covered.
How will this coverage work for Priority Health members?
- Priority Health is working on solutions including point of purchase with no upfront member out-of-pocket costs; however this is in partnership with our Pharmacy Benefits Manager, Express Scripts Intl (ESI) along with their network of pharmacies and will not be operational immediately.
- In the meantime, we’re also developing a direct member reimbursement solution that we’ll communicate more details soon.
Who is this for?
- All Individual Market and Commercial Group members, including self-funded and grandfathered. If an employer does not have pharmacy benefits through Priority Health, they’ll need to work with their Pharmacy Benefits Manager separately.
When can members start to purchase over-the-counter Covid tests for no cost?
- Coverage starts on at-home tests purchased as of Jan. 15, 2022. We anticipate availability of tests will still be limited based on the nationwide shortage and strain on the healthcare system, including pharmacies.
How will members know about this solution?
- Once we have a solution finalized, members will be able to access the most current information on COVID testing and coverage on http://www.priorityhealth.com/covid-19.
We are carefully reviewing and evaluating the new regulations to determine impact and implications. We’ll continue to keep you updated as we know more and finalize solutions.