CMS released additional guidance Feb. 4 on how payers should best cover at-home COVID-19 tests.
The answers to frequently asked questions amend the initial coverage guidance issued by the Biden administration in January.
Five takeaways:
1. CMS is offering flexibility to payers regarding how they establish access to tests — whether it be through a direct-to-member shipping structure or through an in-person pharmacy network. However, to fulfill the requirement of "direct coverage," payers must offer at least one of each method.
2. Payers unable to satisfy direct coverage requirements due to test supply shortages will not be penalized. As long as insurers cover tests procured outside their networks at the $12 per test rate, CMS will not take action against them amid a supply shortage.
3. CMS clarified that payers are expected to report suspected fraud or abuse related to test purchases made by members. To accommodate this, payers may establish guidelines that limit coverage of COVID-19 tests to those received through a healthcare provider or a retailer "that would typically be expected to sell over-the-counter COVID-19 tests."
4. The agency said tests that require self-sampling at home and lab processing are not covered by the guidelines. Tests must be self-administered and read to be covered.
5. Members with flexible spending arrangements or health reimbursement arrangements cannot be reimbursed both through those arrangements and through their health plan. Each test is subject to a single reimbursement, and members who receive duplicate reimbursements are expected to contact administrators to correct the mistake.