As of January 15, 2022, medical plans are required to cover over-the-counter COVID-19 tests without imposing cost-sharing requirements. This requirement was contained in guidance issued by the Treasury and Department of Labor, Health and Human Service that the medical plans provide coverage for specific services and items without cost-sharing.
Texas Covid Test Reimbursement
The federal guidance required medical plans to reimburse customers for at-home COVID-19 tests without imposing the cost-sharing requirement. The medical procedures may limit each member or enrollee to eight OTC tests per month. However, medical plans may not limit coverage of the at-home tests to preferred retailers. In addition, these medical plans can limit reimbursement of OTC tests purchased from a non-preferred store to an amount lesser than $12 (Collins et al., 2022). Here, we will focus on the state of Texas.
Individuals covered by private health insurance or group health plans can purchase FDA-authorized OTC COVID-19 tests and will be able to have those tests covered by their plan. One group of people impacted by this guideline is retired teachers in Texas with specific Medicare Advantage plans. The Teachers Retirement System of Texas indicated that the federal administration did not outspread the at-home test coverage to Medicare plans through their health provider.
TRS-Care Medicare Advantage is following the guideline, and it will not reimburse its members for the at-home rapid tests. However, the Medicare plan will only pay for COVID-19 diagnostic tests such as PCR and antigen performed in a laboratory or when an authorized health provider orders the test.
The Texas Medicaid program, effective January 3, 2022, covers up to four at-home COVID-19 tests per beneficiary per month. This rule is in line with the America Rescue Plan Act of 2021. Texas Medicaid beneficiaries can obtain supplies permitting these at-home tests at any Medicaid-enrolled pharmacy without a doctor’s prescription (Tuggle, 2022).
Employee Retirement System of Texas
The group health plans, including HealthSelect of Texas, Consumer Directed HealthSelect, Out of State plans offered through the ERS, are required to cover the cost of a limited number of specific at-home COVID-19 test kits for their participants. These tests will be covered under an individual’s pharmacy benefits. They must use their prescription insurance card at an in-network retail pharmacy to get these tests at no cost (ERS, 2022).
Coverage allows for only eight per plan per month per member. This plan also covers specific tests, and these tests must be FDA-authorized. The covered OTC test includes; Flowflex Kit Home Test, Quickvue Home Kit COVID-19, Ellume Kit COVID-19 Home Test Kit, BinaxNow COVID-19 Kit Home Test, Inteliswab Kit COVID-19, and On/Go COVID Kit Antigen (ERS, 2022).
It is vital to note that some packages may have two tests. However, the ERS plan covers are based on the number of tests and not the number of boxes. If an individual purchased the OTC test out of network pharmacy or without using a prescription card, they must pay upfront. The test cost can then be submitted through direct management reimbursement. The reimbursement amount is capped at $12 per test (ERS, 2022).
The University of Texas System
Consistent with the Biden rule, starting January 15, coverage has been available under the UT CONNECT and UT SELECT prescription drug program for FDA-authorized OTC test kits at no cost to their members.
Using member UT CONNECT/UT SELECT Express Script prescription drug ID card, members will be able to obtain COVID-19 tests from in-network pharmacies with no out-of-pocket cost. One should, however, bring the test kit to the pharmacy counter. The tests covered are eight per participant per month as per the federal guidelines.
You can submit a manual claim with documentation if you purchase a test kit out-of-network retail store. Reimbursement is limited to $12 per at-home test kit purchased out of network. OTC test kits purchased before January 15 are not eligible for reimbursement under this plan (UTS, 2022).
Blue Cross Blue Shield of Texas
FDA-approved at-home COVID-19 tests will be covered if one has individual or family plan or employer coverage through BCBSTX/Prime Therapeutics pharmacy benefits. Only FDA-APPROVED OTC diagnostic tests purchased on or after January 15 will be covered. Members will be reimbursed up to $12 per test, and up to eight test kits per person per month will be covered.
The OTC test for travel, return to school or work, and recreational events may not be covered. If an in-network store cannot submit your claim electronically, one can submit their prescription drug claim form and attach the original pharmacy receipt (BCBSTX, 2022).
For those on Medicare, the state of Texas said that they will cover the cost of the at-home test just like private insurers.
The Centers for Disease Control and Prevention (CDC) and the Center for Medicare and Medicaid Services (CMS) announced that payments would be available to healthcare providers and physicians to counsel patients at the time of COVID-19 testing concerning the importance of self-isolation after testing positive (CDC, 2020).
Summary
The state of Texas individuals covered by private health insurance or group health plans can purchase an FDA-authorized OTC COVID-19 test and will be able to have those tests covered by their plan. Effective January 3, 2022, Texas Medicaid started covering for at-home tests. Also, for those under Medicare plans, the state government provides coverage for OTC tests. Private insurers such as University of Texas CONNECT, UT SELECT, BCBSTX, and ERS of Texas, provide coverage for FDA-authorized COVID-19 at-home tests for their members.
The maximum number of tests a participant can be reimbursed is eight per month per member. The maximum amount is up to $12 as per the federal guidelines. The insurers, however, cover selected at-home tests, including Flowflex Kit Home Test, Quickvue Home Kit COVID-19, Ellume COVID-19 Kit Home Test, BinaxNow COVID-19 Kit Home Test, and Inteliswab Kit COVID-19, On/Go COVID-19 Antigen Kit. Members can get reimbursement by submitting a form and attaching an original pharmacy receipt.
References
BCBSTX. (2022). What’s Covered – COVID-19 | Blue Cross and Blue Shield of Texas. Bcbstx.com. Retrieved January 28, 2022, from https://www.bcbstx.com/COVID-19/whats-covered.
CDC. (2020). Coronavirus Disease 2019. Centers for Disease Control and Prevention. Retrieved January 18, 2022, from https://www.cdc.gov/media/releases/2020/p0730-cms-cdc-provider-reimbursement-available-COVID-19.html.
Collins, C., Mowery, P., & Rafiq, A. (2022). Health Plan and Insurer Coverage for Over-The-Counter COVID-19 Testing. The National Law Review, 8(28). Retrieved January 29, 2022, from https://www.natlawreview.com/article/health-plan-and-insurer-coverage-over-counter-COVID-19-testing.
ERS. (2022). Coverage of at-home COVID-19 tests | ERS. Ers.texas.gov. Retrieved January 28, 2022, from https://www.ers.texas.gov/what-s-happening-now/coverage-of-at-home-COVID-19-tests.
Tuggle, D. (2022). Reports of problems with reimbursement for at-home COVID tests. Kbtx.com. Retrieved January 28, 2022, from https://www.kbtx.com/2022/01/28/reports-problems-with-reimbursement-at-home-COVID-tests/.
Tuggle, D. (2022). Reports of problems with reimbursement for at-home COVID tests. Kbtx.com. Retrieved January 28, 2022, from https://www.kbtx.com/2022/01/28/reports-problems-with-reimbursement-at-home-COVID-tests/.
UTS. (2022). COVID-19. The University of Texas System. Retrieved January 29, 2022, from https://utsystem.edu/offices/employee-benefits/resources/COVID-19#update17.
