The Biden administration announced that private insurers would have to cover the cost of eight at-home COVID-19 test kits per month per member. According to the Department of Health and Human Services, Americans will be able to get test kits at their health plans preferred retail stores or pharmacies without paying cash. Individuals can also buy them at home tests elsewhere and file a claim for reimbursement.
The administration’s action was intended to expand access to COVID-19 testing and remove financial barriers to most Americans. The insurers’ responsibilities for tests purchased out-of-network would be capped at $12 per test kit. Therefore, individuals would be responsible for additional costs. In addition, if the health plans do not create a network of preferred pharmacies where the cost of at-home tests is covered upfront, it will be responsible for whatever claims its members submit (White House, 2022). This report will focus on the at-home test reimbursement in Washington state.
Some state governments in the United States, including Washington, have invested heavily in rapid testing to counter the latest wave of coronavirus cases. For example, the state that experienced a substantial surge in COVID-19 cases now allows its citizens to pick up four free rapid tests daily at libraries across the city (Weiland & Cliff, 2022).
Washington state launched its Say Yes! COVID-19 Test site, but the state was quickly overwhelmed. Six hours after launching its site, the state stopped taking orders as it only had 650,000 free tests on hand. The state stopped orders with the message, “We have had an overwhelming response to the initiative and have already exhausted the limited supply available for home delivery.” The website reopened for orders, but it was back with a message of unavailability the following day.
The extreme shortage of kits has led to them being sold on social media platforms like TikTok, Instagram, and Facebook, as well as e-commerce websites like eBay with fraudulent mechanisms and inflated prices. The Washington Attorney General tweeted, “We have received reports that unauthorized sellers are trying to profit from the pandemic by selling COVID-19 tests online. Please beware and only buy tests through authorized retailers so you can ensure the integrity of your test.”
Recently, the Washington governor ordered 5.5 million tests, and out of those, 3.5 million tests went to the new amazon-powered web portal. However, the governor did not state when the portal would go online (Woodman, 2022).
How To Get Reimbursed for At-Home Tests
The new coverage requirement means that individuals with private insurers can go to a pharmacy or online, buy the test, and get reimbursed for the cost by submitting a claim to their plan or getting it paid upfront by their health plan. The government incentivized insurers to cover the cost upfront to avoid the need for health physician orders to access the test (Woodman, 2022).
Washington State Health Care Authority (HCA) Apple Health (Medicaid) Program
The HCA Apple Health Medicaid program pays for COVID-19 antigen, molecular, and antibody testing for screening and diagnostic services ordered by a qualified health provider. Only tests with FDA Emergency Use Authorization (EUA) or FDA approved are eligible for reimbursement. A total of $12 per member per test per month is how members can be reimbursed.
Apple Health (Medicaid) covers over-the-counter tests without or with a prescription. A refereed pharmacy claim will be required for reimbursement of an OTC test. When there is no prescription, customers in managed care can contact their managed care plan for billing instructions. In addition, the fee for service clients, pharmacies must use the following prescriber information for billing: prescriber ID Qualifier (466-EZ):01, prescriber ID (407-d7): 5123456787, and prescriber last name: OTC PRODUCT. A total of 12 tests per member per month are covered. However, pharmacies may submit a prior authorization request to HCA (HCA, 2022).
Humana Health Insurance
Humana has a direct coverage option. Therefore, enrollees can purchase the at-home rapid tests at a preferred or in-network pharmacy without paying anything. The company has also laid out guidelines on how members can seek reimbursement for costs they have used at pharmacies outside the preferred network by mailing the claim form with a receipt. However, the organization has not stated the maximum amount to reimburse its members. The OTC COVID-19 tests covered are those authorized and approved by the Food and Drug Administration.
The success of the Biden Administration policy relies on two key factors, including the ability of members to navigate the direct coverage or reimbursement process and the availability of tests. The supply of at-home tests remains limited in many states, including Washing, despite the federal and state governments’ efforts to increase test supply. In the early days of the policy implementation, insurance companies had varying coverage policies, including whether they should have direct coverage or request enrollees to seek reimbursement through mail or online or via fax (Dawson et al., 2022).
Additional Information
Effective January 15, 2022, private insurance companies will be required to cover the cost of eight at-home COVID-19 tests per month per member. States like Washington have invested heavily in rapid at-home testing to counter the recent wave of coronavirus cases. The state now allows its citizens to pick up four tests daily at libraries across the city. With the launching of Say Yes! COVID-19 Test site to increase access to COVID-19 testing, the state still suffers from a limited supply of test kits. Insurance companies like HCA, Apple Health (Medicaid) program, and Humana cover FDA-approved OTC COVID-19 tests. The HCA Apple Health reimburses a maximum of $12 per test kit purchased from network retailers or pharmacies. On the other hand, Humana has not indicated the maximum amount that members can be reimbursed for tests bought at not preferred pharmacies.
References
Dawson, L., Amin, K., Kates, J., & Cox, C. (2022). How Are Private Insurers Covering At-Home Rapid COVID Tests? KFF. Retrieved February 1, 2022, from https://www.kff.org/policy-watch/how-are-private-insurers-covering-at-home-rapid-COVID-tests/.
HCA. (2022). Apple Health (Medicaid) COVID-19 testing clinical policy. Hca.wa.gov. Retrieved February 1, 2022, from https://www.hca.wa.gov/assets/billers-and-providers/apple-health-COVID-testing-clinical-policy.pdf.
Weiland, N., & Cliff, S. (2022). Insurers Will Have to Cover 8 At-Home Virus Tests Per Month. Nytimes.com. Retrieved February 1, 2022, from https://www.nytimes.com/2022/01/10/us/politics/insurance-COVID-tests.html.
White House. (2022). Fact Sheet: The Biden Administration to Begin Distributing At-Home, Rapid COVID-19 Tests to Americans for Free | The White House. The White House. Retrieved February 1, 2022, from https://www.whitehouse.gov/briefing-room/statements-releases/2022/01/14/fact-sheet-the-biden-administration-to-begin-distributing-at-home-rapid-COVID-19-tests-to-americans-for-free/.
Woodman, C. (2022). Insurance To Cover At-Home COVID-19 Tests in Washington. News.yahoo.com. Retrieved February 1, 2022, from https://news.yahoo.com/insurance-cover-home-COVID-19-190828042.html.
