Companies Make clear Necessities for Plan Protection of OTC COVID-19 Checks


The DOL, IRS, and HHS have issued extra FAQ steering addressing the phrases and circumstances underneath which group well being plans should cowl over-the-counter (OTC) COVID-19 diagnostic exams. The FAQs construct on earlier steering (FAQs Half 51), which clarified that, through the COVID-19 public well being emergency, group well being plans should cowl OTC COVID-19 exams that may be self-administered and self-read with out the involvement of a well being care supplier (see our Checkpoint article). Listed here are highlights of the extra FAQs:

  • Direct Protection Protected Harbor. FAQs Half 51 established a secure harbor for plans offering direct protection of OTC COVID-19 exams by means of their pharmacy networks and a direct-to-consumer delivery program—permitting such plans to cap reimbursement for exams bought from non-preferred sellers at $12 per take a look at (or the precise buy value, if decrease). Below the secure harbor, plans should be sure that individuals have satisfactory entry to OTC COVID-19 exams with no upfront out-of-pocket expense. A brand new FAQ clarifies that “satisfactory entry” usually requires plans to make obtainable “not less than one direct-to-consumer delivery mechanism and not less than one in-person mechanism.” A direct-to-consumer delivery mechanism can embrace on-line or phone ordering and could also be supplied by means of a pharmacy or different retailer, the plan or insurer straight, or every other entity on behalf of the plan or insurer. A plan will likely be thought of to have supplied a direct-to-consumer delivery mechanism if the plan offers direct in-person protection by means of specified retailers, and people retailers preserve on-line platforms the place people can order exams to be delivered. Plans should cowl cheap delivery prices in keeping with different gadgets supplied through mail order. Plans implementing in-person mechanisms should guarantee entry to an satisfactory variety of buy places, and the FAQs determine details and circumstances the companies will take into account when figuring out adequacy. Plans needn’t cowl all manufacturers of OTC COVID-19 exams underneath a direct protection program. Reasonably, direct protection could also be restricted to exams made by sure producers, akin to these with which the plan has a contractual relationship or from which the plan is ready to receive exams straight.

  • Insufficient Provide. An in any other case compliant plan is not going to be thought of out of compliance with the secure harbor whether it is briefly unable to offer satisfactory entry by means of its direct protection program as a consequence of a provide scarcity. The plan could proceed to restrict reimbursement to $12 per take a look at for exams bought exterior of the direct protection program.

  • Fraud Prevention. Plans could restrict protection of OTC exams bought with out the involvement of a well being care supplier to exams bought from established retailers that might usually be anticipated to promote OTC COVID-19 exams. Plans could disallow reimbursement for exams bought from a personal particular person through an in-person or on-line person-to-person sale or from a vendor that makes use of a web based public sale or resale market. Individuals ought to be knowledgeable of any limitations on the sorts of sellers from which exams have to be bought.

  • House-Assortment PCR Checks. The OTC steering in FAQs Components 51 and 52 is inapplicable to exams akin to home-collection PCR exams the place a person collects a specimen at house and sends it to a laboratory for processing. Nonetheless, plans should cowl most of these exams in accordance with the foundations for exams ordered by a well being care supplier.

  • Well being FSAs, HRAs, and HSAs. Though the price of an OTC COVID-19 take a look at is a medical expense usually reimbursable by a well being FSA or HRA, a person can’t be reimbursed greater than as soon as for a similar expense. Thus, the price (or portion of the price) of a take a look at paid or reimbursed by a plan or insurer can’t be reimbursed by a well being FSA or HRA. Likewise, an expense “compensated for by insurance coverage or in any other case” will not be a professional medical expense for HSA distribution functions. Plans and insurers could want to advise their individuals to not search reimbursement from a well being FSA or HRA for a take a look at that was paid or reimbursed by the plan or insurer and to not use a well being FSA or HRA debit card to buy exams for which the participant intends to hunt reimbursement from the plan. People who mistakenly obtain reimbursement from a well being FSA or HRA for exams lined by one other plan ought to contact the well being FSA or HRA administrator relating to correction procedures. People who mistakenly take a distribution from an HSA should both embrace the distribution in gross earnings or, if permitted, repay the distribution to the HSA.

EBIA Remark: These extra FAQs present helpful clarifications for plans and insurers scrambling to adjust to the OTC protection requirement that took impact January 15, 2022. These implementing a direct protection possibility will welcome the extra flexibility described within the FAQs. For extra info, see EBIA’s Group Well being Plan Mandates guide at Part XVI.C (“COVID-19: Mandated Protection of Diagnostic and Preventive Providers”). See additionally EBIA’s Self-Insured Well being Plans guide at Part XIII.C.11 (“Protection Mandates Referring to the COVID-19 Pandemic”), EBIA’s Shopper-Pushed Well being Care guide at Sections XV.C (“What Is an HSA-Certified Medical Expense”) and XXIV.B (“HRAs Might Reimburse Solely Code § 213(d) Bills”), and EBIA’s Cafeteria Plans guide at Part XX.I (“Expense Can not Be Reimbursed (and Participant Should Certify That Reimbursement Will Not Be Sought) From Different Well being Plan Protection”).

Contributing Editors: EBIA Workers.


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