Getting Coverage for At-Home COVID Testing

Coverage For At-Home COVID Testing

Starting on January 15, 2022,  most people with a health plan can purchase an at-home COVID-19 diagnostic test authorized by the U.S. Food and Drug Administration (FDA) at no charge. Depending on your health plan, the test may be free over-the-counter when you purchase it at participating “in-network” pharmacies. Or, you might have to submit a claim for reimbursementin which case you should save your receipts.

Below you will find communications from:

  • Blue Cross
  • HAP
  • McLaren Health
  • Priority Health 
  • UnitedHealthcare

As we receive the latest testing coverage information, we will post updates to this page. As always, our team is standing by, ready to serve all your insurance needs. Should you have any further questions, please do not hesitate to contact us.

 


Blue Cross and BCN responds to requirement for at‑home COVID-19 testing coverage

Details about the new program as stated by Blue Cross and BCN

Blue Cross, BCN provide more information about COVID-19 at-home test kits

 


Blue Cross, BCN Provide More Info About COVID-19 at-home Test Kits

Updated April 2022

Blue Cross announced updated information related to their preferred pharmacy network and direct-to-consumer solution for groups with pharmacy benefits. Read more

 


What you need to know
Blue Cross Blue Shield of Michigan and Blue Care Network are adding new options for members who have our pharmacy coverage to get over-the-counter, at-home COVID-19 tests.

Here are some key points:

  • As we announced earlier, the federal government is offering four free tests to all households at covidtests.gov.* We will continue to remind audiences of this availability.
  • Blue Cross and BCN are launching a preferred pharmacy network for over-the-counter, at-home COVID-19 tests, effective Feb. 1, 2022. The network enables commercial members with Blue Cross or BCN pharmacy coverage to obtain a number of free COVID-

    19 tests when purchased in person at a preferred pharmacy. The preferred COVID-19 test network includes Walmart, Rite Aid and Sam’s Club pharmacies. Members must get the tests through the pharmacy counter by presenting their Blue Cross or BCN ID card.

  • For reimbursement of purchases at nonpreferred pharmacies, a new form will be available at bcbsm.com on Feb. 1, 2022, that uses our pharmacy benefit manager to process these claims. Commercial members with Blue Cross and BCN pharmacy coverage will be able to use this form to apply online for reimbursement at $12 or the cost of the test, whichever is lower

How to find a preferred pharmacy
The preferred network for over-the-counter, at-home COVID-19 tests will include pharmacies
within Walmart, Sam’s Club, and Rite Aid stores. Beginning Feb. 1, 2022, new information will be
posted about the preferred network at bcbsm.com/coronavirus.

Groups without pharmacy benefits through Blue Cross and BCN are not eligible
Customer groups who do not have Blue Cross or BCN pharmacy benefits must work with their
own pharmacy benefit manager to set up a way to obtain tests. These customer groups should
be encouraged to communicate to their employees about how they can obtain a test at no cost
through their pharmacy benefit manager.

Additional information
• Tests must be authorized by the U.S. Food and Drug Administration.
• Tests must be purchased on or after Feb. 1, 2022, to qualify for the preferred network.
• Up to eight qualifying at-home tests can be obtained per member each month.
• An order from a qualified health professional is not required to obtain over-the-counter,
at-home tests from one of the network pharmacies

In addition, the tests must be authorized by the U.S. Food and Drug Administration. The FDA lists all authorized tests on its website, but there are steps members need to take to find them:

Please note
• Reimbursement does not apply for tests used for employment purposes.
• The new program does not include Medicare Advantage plans. Please visit the senior COVID-19 site that we’ve created just for our Medicare members to learn about how they can access COVID-19 testing in other ways.
• Some COVID-19 tests kits include two tests per box. Those kits would count as two tests.

Blue Cross and BCN continue to pay for COVID-19 testing in other instances
• Blue Cross will still cover other types of COVID-19 diagnostic tests if they are FDA authorized and ordered by a qualified health professional.
• Coverage is under the medical plan.
• This is also explained at bcbsm.com/coronavirus

When to use COVID-19 test kits
Testing is an important tool to help mitigate the spread of COVID-19. Public health experts and the Centers for Disease Control and Prevention recommend that Americans use at-home tests if they begin to have symptoms, at least five days after coming in close contact with someone who has COVID-19 or are gathering indoors with a group of people who are unvaccinated or at risk of severe disease.

 


HAP responds to requirement for at‑home COVID-19 testing coverage

Details about the new program as stated by HAP:

In accordance with federal guidelines, private health insurers, including HAP, are required to cover up to eight (8) at-home over-the-counter COVID-19 diagnostic tests authorized by the U.S. Food and Drug Administration (FDA) beginning January 15, 2022.

Important note: Insurers, including HAP, cannot control the supply and availability of at-home testing kits. Many pharmacies and retailers continue to experience supply delays that are beyond their/our control.

A complete list of at-home testing kit guidelines can be found on the Centers for Medicare and Medicaid Services (CMS) website.

Who is eligible?

HAP will cover the cost of at-home tests, as noted above, for its Commercial members. This includes members of HAP’s large and small employer group plans (including self-funded plans), as well as individual members who purchase their own health plans.

Those not included in this program are Medicaid, Dual Special Needs (D-SNP), and Medicare members, including those with Medicare coverage through a group plan (such as an employer-sponsored Medicare plan). Information for Medicare and Medicaid members can be found below.

How many tests are covered?

In accordance with federal guidelines, HAP will cover up to 8 at-home tests per member per month. If a kit contains multiple tests, each test counts as one. So, a kit with two tests in it would count as two tests toward the eight.

If I don’t purchase 8 tests in a month, can that carry over into the following month?

No, there is no carryover allowance. The limit is 8 tests per calendar month per Commercial member.

If a doctor orders me to be tested, does that count toward my monthly limit?

No. COVID-19 diagnostic tests that are ordered or administered by a health care provider do not count toward your limit of 8 tests per month. In most cases, HAP covers the cost of tests ordered by a health care professional with no cost share to the member.

Is there a price limit on the covered tests?

If you purchase a test from a pharmacy in our preferred network, you will have no cost-sharing. If you purchase a test outside this network, in accordance with federal guidelines, HAP will reimburse members at a rate of up to $12 per individual test (or the cost of the test, if less than $12).

Will HAP reimburse me for more than 8 tests per month if my employer requires regular testing as a condition of my employment?

No. In accordance with state and federal guidelines, HAP does not cover the cost of testing required by employers.

Which at-home tests are covered by HAP?

HAP will cover the cost of over-the-counter at-home test kits that are authorized by the FDA. The FDA maintains a list of approved antigen diagnostic tests and approved molecular diagnostic tests on its website.

Can I buy tests for my whole family at one time?

HAP will cover the cost of up to 8 tests per member per month, regardless of whether they are purchased all at once or at separate times during that month. Retailers and pharmacies are responsible for ensuring eligibility; they may require that members are present or may have other policies to ensure eligibility. HAP is not responsible for the policies of retailers.

Where can I purchase at-home testing kits that are covered by HAP?

HAP has a network of preferred pharmacy providers. When purchasing or ordering an FDA-approved kit from a preferred provider, show your HAP ID card, and the provider will bill HAP directly. You should incur no out-of-pocket cost. To access the list of HAP’s preferred pharmacy networks, click here.

To request an at-home test kit via mail order from Pharmacy Advantage, click here. Submit as a general request with the subject “Other” and include the message: “Would like to request an OTC COVID Test kit.” A Pharmacy Advantage team member will contact you to gather all necessary information and process your request. The estimated fulfillment time is 5 to 7 business days.

If HAP’s preferred providers don’t have any kits available, can I purchase one elsewhere?

If you purchase a kit from a preferred provider, you should incur no out-of-pocket costs. If you purchase a kit from a non-preferred provider, HAP will reimburse you up to $12 per at-home, over-the-counter COVID-19 diagnostic test authorized by the FDA, or the cost of the test if it is less than $12.

What if a preferred pharmacy or provider tries to bill me?

A participating provider should always bill HAP directly. However, if you pay for the test, submit your receipt to HAP (instructions are below).

How do I get reimbursed by HAP?

To receive reimbursement for a testing kit purchased January 15, 2022, or later, you must submit your receipt along with the completed and signed reimbursement form that shows the purchase date, test kit name, UPC or SKU code (from box or label), cost of the kit, number of tests within each kit and where it was purchased. That form can be accessed here.

Submit the completed reimbursement form and receipt to:

HAP Claims Division
Pharmacy Reimbursement
2850 W. Grand Blvd.
Detroit, MI 48202

I bought some at-home testing kits prior to January 15. Can I be reimbursed?

No. In accordance with federal guidelines, HAP will cover the cost of approved testing kits (as noted above) beginning January 15, 2022. Kits purchase prior to that date are not eligible for reimbursement.

Are my at-home tests covered if I’m traveling or living outside of Michigan?

Yes. If you are traveling or living outside of the state of Michigan and purchase a testing kit from a non-preferred provider, submit your request for reimbursement as noted above.

 


McLaren Health Plan to Reimburse for COVID-19 OTC Test Kits

Effective Jan. 15, McLaren Health Plan will reimburse group and individual health plan members for Over-the-Counter (OTC) COVID-19 test kits. This does not apply to people with Medicaid or Medicare coverage.

McLaren Health Plan members must purchase authorized test kits and submit a Direct Member Reimbursement form to receive payment. The following Q&As can be found on our website under ‘Are You a Member?’, ‘Are You an Agent’ and ‘Are You an Employer?’ and under ‘Learn More, COVID-19 Updates.’

WHO CAN GET REIMBURSED FROM MCLAREN HEALTH PLAN FOR THE COST OF AN OTC COVID-19 TEST KIT?

The legislation applies to people covered in group health plans (through an employer) and those with private individual health insurance.

Medicare and Medicaid members are not eligible for reimbursement through McLaren Health Plan. You can get a COVID-19 test at no cost from www.COVIDTests.gov or when ordered or administered by a health care provider, like a nurse, doctor or pharmacist. Click here for a list of community-based sites that provide testing.

ARE THERE LIMITS ON THE AMOUNT OF TESTS FOR WHICH I CAN GET REIMBURSED?

Yes. A covered person can purchase and get reimbursed for eight FDA-authorized tests per 30 days. This means a family of four can be reimbursed for 32 tests per month. Use the Direct Member Reimbursement (DMR) form found here. Claims for reimbursement must include proof of purchase, such as a prescription receipt and the UPC Code from the package.

Test kits must be authorized, cleared or approved by the U.S. Food and Drug Administration (FDA). McLaren Health Plan is not able to reimburse purchases from unauthorized sources including – but not limited to – friends or neighbors, Facebook Marketplace, etc. Reimbursement is subject to review under McLaren Health Plan’s fraud, waste and abuse policies.

Many retailers are currently experiencing shortages of tests and limiting the number that may be purchased per household. McLaren Health Plan will continue to provide coverage for COVID-19 tests that are ordered or administered by a health care provider at no member cost share.

HOW MUCH WILL I GET REIMBURSED PER TEST IF I DECIDE TO PURCHASE ONE?

McLaren Health Plan will reimburse you for the cost of the test, subject to review for fraud, waste and abuse. Upon implementation of our direct access program, you will get reimbursed $12 per test or the amount of your actual purchase price, up to $12. There are no deductibles, copayments or coinsurance, prior authorization, or other medical management requirements. Use the Direct Member Reimbursement (DMR) form found here. Claims for reimbursement must include proof of purchase, such as a prescription receipt and the UPC Code from the package.

WHAT IF I CAN’T AFFORD TO PAY FOR THE TEST UP FRONT?

You have options other than to purchase a test and get reimbursed. As of Jan. 19, you can go to www.COVIDTests.gov and order tests with no up-front payment required. There are many free testing sites in Michigan where you can get a test. A list of community-based sites can be found here. Tests also are available without cost-share to covered persons when given by a health care provider, like a nurse, doctor or pharmacist.

IS REIMBURSEMENT AVAILABLE FOR OTC AT-HOME COVID-19 TESTS I PURCHASED BEFORE JAN. 15, 2022?

No. Reimbursement for OTC at-home COVID-19 tests is only available for those tests purchased on or after Jan. 15, 2022.

WHAT IF I HAVE ADDITIONAL QUESTIONS?

Please call our customer service team at 888-327-0671 (TTY: 711).


Priority Health responds to requirement for at‑home COVID-19 testing coverage

New regulations were 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.

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 meant time, we’re also developing a direct member reimbursement solution that we’ll communicate more details soon.

Who is this for?

  • All Commercial Group and Individual Market 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.

COVID-19 OTC test kit reimbursement form

When can members start to purchase OTC 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 solutions finalized, members will be able to access the most current information on COVID testing and coverage on www.priorityhealth.com/covid-19.

We continue to carefully review and evaluate the new regulations to determine impact and implications. We’ll continue to keep you updated as we know more and finalize solutions.

 


UnitedHealthcare responds to requirement for at‑home COVID-19 testing coverage

Details about the new program as stated by UnitedHealthcare

  • Beginning January 15, 2022, UnitedHealthcare will cover most commercial individual, and group health plan members’ FDA authorized or approved over-the-counter (OTC) at-home COVID-19 diagnostic tests without a doctor’s prescription. This at-home COVID-19 test benefit includes up to 8 tests per member per month. This new benefit does not apply to Medicare Advantage. However, Medicare members should check their plan coverage for specific OTC benefits. Medicaid benefits apply in the following states at this time: New Jersey, New York, North Carolina, Michigan, Texas, and Washington.
  • UnitedHealthcare’s initial preferred OTC retailers for at-home COVID-19 tests are Walmart Pharmacy and Rite Aid Pharmacy (including Bartell Drug locations), where members who have UnitedHealthcare Pharmacy benefits are administered by OptumRx will have no up-front cost and will not have to submit a form for reimbursement. UnitedHealthcare is working to add additional preferred retailers.
  • If the member purchases an at-home COVID-19 test at any in-store or online retailer other than the in-store Walmart Pharmacy counter or in-store Rite Aid Pharmacy counter, they may submit purchase receipt(s) for reimbursement at the UnitedHealthcare member portal for a maximum reimbursement of $12 per test. Many COVID-19 tests are sold as a two-pack so that means the test pack would be reimbursed at $24 ($12 for each test).
  • A member must be a UnitedHealthcare commercial individual or group health plan member and have UnitedHealthcare’s Pharmacy benefit, to purchase over-the-counter at-home COVID-19 tests at the Walmart Pharmacy or Rite Aid Pharmacy counter at no cost. Members may determine their eligibility by locating the OptumRx logo on the front of the member I.D. card. This informs the member they are part of the UnitedHealthcare pharmacy benefit through OptumRx and may go to any Walmart Pharmacy or Rite Aid Pharmacy with available inventory to get a COVID-19 over-the-counter test at no cost when purchased at the pharmacy counter.

For groups that do not have the UnitedHealthcare pharmacy benefit through OptumRx (Optum RX is not displayed on the I.D. card), the member may purchase an at-home COVID-19 test at any in-store or online location and submit it for reimbursement in the UnitedHealthcare member portal. You may receive more specific guidance from your employer on this benefit in the future.

Under the January 10 Tri-Agency FAQ 51, what is considered an at-home test?

These are tests that have been authorized, cleared, or approved for use without a doctor’s prescription. The tests may be purchased without the need for a provider or clinical assessment.

How do we know which kits are FDA approved?

The list continues to evolve as additional FDA emergency use authorizations occur. Authorized or approved OTC at-home tests are listed on the FDA website. Test kits purchased from a non-authorized seller are not eligible for reimbursement.

How many COVID-19 tests will be allowed per patient, per month?

Each covered member can be reimbursed for 8 over-the-counter COVID-19 tests every 30 days per covered member. Some test kits contain 2 tests per kit — each of those tests is counted individually toward the limit of 8 per month. For example, if a covered member purchases 4 tests kits with 2 tests in each kit, that equals 8 tests for the month for that member.

Does UnitedHealthcare offer direct purchase through a preferred retailer as well as reimbursement through claim/receipt?

Yes. For fully insured and self-funded customers with a carve-in pharmacy program, UnitedHealthcare offers a preferred retailer program (Walmart Pharmacy). When the member purchase from the pharmacy at the retailer with their I.D. card, it will be paid directly. UnitedHealthcare is working to add more preferred retailers.

Please review the COVID-19 At Home Test FAQs on the uhc.com COVID-19 FAQ.

COVID-19 At Home Test member FAQs also available here.

 


Covid Testing and Preventative Services Forms – from Larry Grudzien

On January 10, 2022, the Biden Administration released guidance on requiring both insured and self-funded group health plans to provide free Coronavirus testing to employees and dependents by January 15, 2022 and coverage for certain preventive services.

 Are you ready to communicate the new requirements to your employees?

Attorney Larry Grudzien &  Howard Lapin have created Coronavirus testing and preventive services forms. These forms include

  • A notice form which informs employees of the rules for receiving reimbursement for tests and what tests can be reimbursed.
  • A attestation form which is used for employees to promise not to resale the tests and communicate that the tests are only for personal use.
  • An amendment for the medical plan which details the new requirements for providing coverage for the Coronavirus testing and preventive services.
  • A Summary of Material Modifications for the Medical Plan’s Summary Plan Description which explains the new coverage requirements for Coronavirus testing and preventive services.

When you order these forms, they will be provided to you in a Word file and can be easily branded for use with your clients.

How do I order?  You can purchase these forms for only $35. If you ordered one of the other Forms Packages in the past, you will receive a $5 discount.

Both checks and credit cards are accepted. If you are paying by check, please send to

 Larry Grudzien

Attorney at Law

708 So. Kenilworth Ave.

Oak Park, IL 60304

If you are paying by credit card, please contact Larry by phone. Please do not include any credit card numbers in an e-mail, unless the e-mail is secure. As soon as payment is received, Larry will send you a copy of the forms.

Questions? If you have any questions before or after ordering these forms, please

call (708) 717-9638 or e-mail larry@larrygrudzien.com

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