Compliance News | January 13, 2022
Group health plans and insurers must cover over-the-counter COVID-19 tests without cost-sharing, prior authorization or other medical management requirements, according to new guidance. The guidance from the Departments of Labor, Health and Human Service, and Treasury implements the ACA and CARES Act requirements to cover certain COVID-19 in vitro diagnostic COVID-19 tests without cost-sharing.
The guidance also contains new information concerning how non-grandfathered plans must cover colonoscopies and other preventive services.
Under the guidance, FAQ 51:
The guidance on over-the-counter COVID-19 tests takes effect on January 15, 2022 and is prospective. Before the January 15, 2022 effective date of the guidance, plans may choose to cover over-the-counter COVID-19 tests purchased without a provider order or individual clinical assessment.
Plans must continue to provide coverage for COVID-19 tests that are administered with a provider’s involvement or prescription. Like the other COVID-19 testing coverage requirements in the CARES Act, the requirement does not appear to apply to retiree-only plans.
Plans may take reasonable steps to address fraud and abuse, including requiring participants to sign an attestation that the over-the-counter test was purchased for the individual’s own personal use, or by use of a covered family member.
Plans may also establish filing requirements for claim submission, including requiring appropriate receipts.
The Departments encourage plans to provide education and information resources to support consumers seeking OTC COVID-19 tests. Communication could include guidance to support access to approved tests and information about when to use them. The Departments also published consumer information in a post entitled, “How to Get Your At-Home Over-the-Counter COVID-19 Test for Free.”
These new requirements are likely to lead to short-term increases in plan costs.
Our Health Practice will soon share initial estimates.
For plan years beginning on or after May 31, 2022, the guidance requires non-grandfathered plans to cover without cost-sharing a follow-up colonoscopy conducted after a positive non-invasive stool-based screening test or direct visualization test (e.g., sigmoidoscopy, CT colonography). The Departments state that the colonoscopy conducted after such a positive test is an integral part of the preventive screening process.
Additionally, the guidance reminds non-grandfathered plans that all FDA-approved, cleared or granted contraceptive products that are medically appropriate must be covered without cost-sharing, even if they are not specifically identified in the current FDA Birth Control Guide.
In response to this guidance, plan sponsors should consider taking following steps:
This page is for informational purposes only and does not constitute legal, tax or investment advice. You are encouraged to discuss the issues raised here with your legal, tax and other advisors before determining how the issues apply to your specific situations.
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