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How Private Payers, Medicaid Cover At-Home COVID-19 Testing

In the early days of mandatory coverage for at-home COVID-19 tests, major payers are fairly split on whether to provide direct coverage for at-home COVID-19 testing.

Kelsey Waddill
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Published: 21 Jan 2022

A handful of the largest private payers are evenly split regarding whether they provide direct coverage for at-home COVID-19 testing, according to the Kaiser Family Foundation (KFF) which assessed both coverage for at-home coronavirus testing among some of the larger private payers and Medicaid coverage for at-home coronavirus testing 

Ever since CMS announced that payers would have to cover at-home coronavirus testing, payers have been scrambling to establish the necessary processes to comply. The requirement went into effect on January 15, 2022 and gave commercial health insurers two options for how to reimburse for tests: upfront, direct coverage or claims reimbursement.

CMS incentivized payers to reimburse for tests through direct coverage so that members would have no financial barriers at the pharmacy counter or shopping online for at-home coronavirus tests.

Meanwhile, Medicaid programs are also exhibiting a range of responses to required at-home COVID-19 testing coverage.

Private payers

KFF researchers reviewed 13 insurers’ websites from January 18 through January 20, 2022.

Of the 13 private insurers that KFF assessed, six insurers were providing direct coverage for the at-home tests: Blue Cross Blue Shield of North Carolina, Centene or Ambetter, Health Care Service Corporation (HCSC), Guidewell or Florida Blue, Humana, and United Health Group’s commercial plans. Kaiser Permanente plans to offer direct coverage in the future but does not currently do so.

Most of the insurers that allow for direct coverage—five out of the six companies—also will cover out-of-network cost reimbursement, mostly by mail. Five of the insurers that offered direct coverage added that out-of-network cost reimbursements will be capped at $12 per test. Humana did not note the reimbursement cap.

Four insurers— Blue Cross Blue Shield of Michigan, Blue Shield of California, Care First, and Cigna— require members to mail their receipts to the payer for reimbursement. Cigna also allows members to fax their receipts. 

Two of the insurers, Anthem and Kaiser Permanente, reimbursed online. CVS Health did not publicly provide information about the company’s reimbursement strategy.

The researchers cited a common refrain among the payer community regarding how at-home coronavirus test availability could render insignificant the efforts to reduce financial barriers. Previous research from KFF found that at-home coronavirus tests were in low supply before CMS issued the new requirement.

“The success of this policy hinges on two main factors: the availability of tests and the ability of enrollees to navigate the reimbursement or direct coverage process,” the researchers concluded. “If supply remains limited and tests are not widely available, a reimbursement or direct coverage mechanism does not do much to improve access.”

Medicaid

Medicaid programs have to cover at-home coronavirus tests that have been approved by the Food and Drug Administration (FDA) without cost-sharing, which aligns with the American Rescue Plan Act. However, states have some flexibility in how they implement the Medicaid policy. 

KFF researchers assessed five states’ guidance on Medicaid coverage for at-home coronavirus tests.

In North Carolina, as of January 10, 2022, the Medicaid program will cover up to four test kits every 30 days. Medicaid-enrolled pharmacies can bill the Medicaid program and there is no copayment for beneficiaries.

In Massachusetts, as of January 14, 2022, Medicaid will cover up to eight test kits per member per month. A beneficiary can acquire more tests if they have a prior authorization. These kits are covered under the Medicaid program’s pharmacy benefit.

In Maine and Vermont, pharmacies can bill for certain at-home tests. In these states, pharmacists are considered the prescriber.

New York requires an order form a Medicaid-enrolled practitioner in order to cover the testing kits and covers up to one kit per week. However, actual billing and reimbursement policies may vary in the state based on the managed care organization.

Although many payers have found that establishing coverage for at-home coronavirus tests has been a fast and challenging process, data shows that patients are more likely to share at-home tests with their communities and most patients are receptive to such a strategy, which could indicate that these tests are successfully increasing access to testing.

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