CMS Requires Payers to Cover At-Home Coronavirus Testing

January 11, 2022 - Updated 1/11/2022: This article has been updated to include comments from leaders at the Alliance of Community Health Plans (ACHP).

Health insurers will be responsible for the costs of at-home coronavirus testing, CMS announced.

“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. “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.”

Starting on January 15, 2022, commercial health insurers will have to pay consumers for their at-home coronavirus tests. 

Health plans can reimburse the cost after the fact or cover the costs upfront. But the two methods are not created equally. When a payer commits to cover costs upfront so that consumers do not pay anything at the counter, consumer purchases that are out-of-network can be reimbursed up to $12. 

READ MORE: ACHP Asks CMS To Set At-Home COVID-19 Testing Coverage Standards

Payers that choose to reimburse claims for at-home coronavirus tests instead of covering it at the counter will have to pay full price for purchases that occur out-of-network.

However, payers are not expected to cover a limitless number of at-home coronavirus tests. Insurers must cover eight free at-home coronavirus tests per person per month, or as many as 32 tests each month for a family of four on the same health plan. The tests must have been authorized, approved, or cleared by the US Food and Drug Administration (FDA).

Additionally, individuals that are ordered by a provider to receive an at-home coronavirus test must receive coverage for all ordered tests.

The announcement comes at a time when access to coronavirus testing is essential due to the Omicron variant which is surging across the US.

“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.

READ MORE: Biden Plan Expands COVID-19 Testing Coverage, Booster Outreach

In particular, some experts have noted that at-home coronavirus testing kits could be key to preventing the spread of the disease by expanding access to tests.

CMS released two frequently asked question sheets to respond to particular issues, one for healthcare stakeholders and one that targeted the general public.

Payers have largely voiced their readiness to comply with the administration’s announcement specifically calling out the potential to reduce price gouging.

“Every day, more Americans are being diagnosed with COVID-19. From the beginning, health insurance providers have taken decisive action to cover the costs of tests to diagnose and treat COVID-19 – and we continue to do so,” said Matt Eyles, president and chief executive officer of AHIP, in a statement. 

“We learned a great deal through that commitment and other key actions on COVID-19, and we recognize that the Administration’s guidance takes steps to mitigate the real risks of price gouging, fraud, and abuse, which would limit access and reduce affordability for everyone.”

READ MORE: ACHP: 5 Policy Recommendations about COVID-19 Testing Coverage

However, some payers, including AHIP, expressed concerns about the testing supply and coverage process. Kim Keck, president and chief executive officer of Blue Cross Blue Shield Association, echoed AHIP’s sentiments but added a note of concern.

“We are concerned that the policy does not solve for the limited supply of tests in the country and could cause additional consumer friction as insurers stand up a program in just four days’ time,” Keck shared in a statement. “We will continue to partner with the administration and retailers to help make this work and advocate for policies that promote affordable and equitable access.”

The Alliance of Community Health Plans (ACHP) was particularly vocal about the need for established requirements for at-home coronavirus testing coverage.

The organization urged the administration to require that claims include the cause for the test, standardize at-home coronavirus testing frequency recommendations, brace against fraud, deal with price gouging, and set aside a timeframe for at-home coronavirus testing claims submission.

In response to this latest CMS announcement, ACHP leaders continued to express reservations about the administration's approach to coronavirus testing.

"We appreciate our ongoing, constructive conversations with the Administration regarding test accessibility and our shared goals to protect the American public. However, the lack of a coordinated national testing strategy two years into this public health emergency leaves too many communities without the resources necessary to mitigate this virus," Ceci Connolly, president and chief executive officer of ACHP, said in an emailed statement. "There are alternatives available to improve access to at-home tests, but this ill-conceived guidance misses the mark.”

“This is a patchwork solution that isn’t actually addressing the underlying issue, which is making sure every American has access to a free test when they need it for an appropriate medical purpose, especially with omicron spreading as it is,” Michael Bagel, director of public policy at ACHP, added.