The Department of Financial Regulation issued an emergency regulation requiring health insurers to cover the costs of COVID-19 antigen at-home tests (commonly referred to as “rapid” tests).
The new rule applies to approximately 140,000 Vermonters who have commercial insurance in Vermont’s individual, small and large group markets as well as the Vermont Education Health Initiative. The emergency rule requires health insurers to cover the retail purchase of most FDA-authorized COVID-19 antigen tests without cost-sharing for home use.
To help maintain an adequate supply of at-home test kits for all Vermonters, coverage is limited to eight test kits per person per month. Health insurers must process and reimburse appropriate claims for tests described in this emergency rule retroactively for tests purchased on or after December 1, 2021.
- Federal Reimbursement Guidance
- Reg. H-2021-02-E
- DFR Press Release
- Department of Health Order about At-Home Antigen Test Kits
- Pharmacy COVID-19 Antigen Test Coverage (DVHA Advisory)
- Report Your Test Results to the Department of Health
If you are not sure if you are covered, contact your insurance provider first.
Consumers with commercial insurance and Vermont Medicaid can get tests covered at no upfront cost through the pharmacy counter.
While all FDA-authorized COVID-19 rapid tests are covered, and will be reimbursed under the Emergency Rule, only certain tests are likely to process correctly through pharmacy claims systems at the moment. These tests include:
- BinaxNow COVID-19 AG Card
- Quickvue at-home COVID-19
- Intelliswab COVID-19 rapid test
- On/Go COVID rapid test
- Who receives At-Home coverage under the emergency rule? The Department’s emergency rule only covers individuals who receive their health insurance through the individual, small group, or large group marketplaces. On January 15, 2021, guidance issued by the federal government takes effect, requiring most private employer health plans to reimburse at-home rapid COVID-19 testing.
- What kind of At-Home tests are covered? Only FDA-authorized SARS-CoV-2 antigen test kits. Additionally, on January 15, 2021, guidance issued by the federal government takes effect, requiring health plans to reimburse all at-home rapid COVID-19 tests with Emergency Use Authorization from the Food and Drug Administration.
- What if I don’t have a prescription for a Covid-19 At-Home Antigen Test Kit? On December 13, 2021, Commissioner of Health Dr. Mark Levine issued a standing order that may be used by Vermont residents as a prescription or third-party prescription to obtain Covid-19 At-Home Antigen Test Kits. For purposes of reimbursement, consumers may list Dr. Levine as the ordering provider.
- How does a covered individual file a reimbursement claim? They should file a claim reimbursement form with the receipt for the at-home test purchase with their insurance company. Links to the claims form can be found here:
- Blue Cross Blue Shield of Vermont: https://www.bluecrossvt.org/documents/member-claim-form
- MVP: https://www.mvphealthcare.com/wp-content/uploads/download-manager-files/CVS-Caremark-Prescription-Reimbursement-Claim-Form-for-MVP-Health-Care.pdf
- CIGNA: https://www.cigna.com/assets/docs/Cigna%20notices-of-privacy-practices/pharmacy-forms/pharmacy-claim-form.pdf?WT.z_nav=memberrightsandresponsibilities%2Fmember-forms%3Baccordion%3BPharmacy%20Forms%3BPharmacy%20Claim%20Form
- Does this Rule apply to Medicare Part D and Medicare Advantage? No. Those are Federal plans and you will need to contact the customer service number on your ID Card.
If kits are ordered through Amazon or other online retailers will there be coverage? Yes. As long as tests ordered online are FDA-authorized and you follow the correct claims process for your insurance provider.
If a pharmacist has a question who should they call? They should call the company that they work for to get clarification.
If a member exceeds the coverage limit set forth in Section 3, it’s up to the insurer whether coverage of additional test kits will be denied or covered with cost sharing. However, if the test would otherwise constitute a covered service within the meaning of the subscriber’s contract, the Department would expect insurers to cover it with applicable member cost-sharing.
Consistent with 1 V.S.A. § 124, the term “month” in Section 3 means calendar month (i.e., December).
Under section 6, the Emergency Rule will apply to the extent it doesn’t conflict with federal law. Therefore, if the Emergency Rule is more generous than the forthcoming federal guidance (expected to be issued on January 15, 2022), the Department would expect insurers to continue to apply the Emergency Rule unless the feds decide to clear the field and preempt state authority.
If a test kit has more than two tests, insurers must cover it to the extent mandated under section 3. For instance, for a hypothetical test kit with 6 tests, that would count as 6 of the 16 total discrete tests. The Department is aware that these test kits are being sold in packs of 100 or more online, and it’s not our intent to require insurers to cover those kinds of bulk purchases. If a member is buying hundreds of tests, it’s unlikely they’re for use in a home setting.
Does the federal guidance taking effect on January 15, 2021 supersede the emergency rule? Under section 6 of the emergency rule, it is not intended or should be construed to be in conflict with federal law. Thus, insurers are required to reimburse tests purchased prior to January 15, 2021, in accordance with the emergency rule, and comply with the federal guidance going forward. While COVID-19 rapid tests remain limited in supply, the Department encourages all health plans to refrain from limiting reimbursement to consumers as provided for in the federal guidance.