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At Home Covid-19 Antigen Test Coverage

Reg. H-2021-02-E
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Section 1.        Background and Purpose.

This emergency rule is adopted under Act 6 of 2021.
The purpose of this emergency rule is to expand health insurance coverage for and waive or limit certain cost-sharing requirements directly related to COVID-19 antigen tests (commonly referred to as “rapid” tests), including over-the counter tests for use at home.
This emergency rule is not intended to affect payment or cost-sharing related to COVID-19 (SARS-CoV-2) testing covered by Emergency Rule H-2021-01-E.

Section 2.        Definitions.


Terms used in this emergency rule shall have the meanings given to such terms, if any, in 18 V.S.A. § 9402.

Section 3.        Coverage of COVID-19 Antigen Tests.


Coverage of COVID-19 (SARS-CoV-2) Antigen Tests. Health insurers shall process all eligible claims for retail purchase of FDA-authorized SARS-CoV-2 antigen test kits without member cost-sharing through the pharmacy benefit. The test kits are to be used by the member in a home setting.
Eligible Claims. Health insurers shall process claims for SARS-CoV-2 antigen test kits in a manner consistent with subsection (a) of this section when:

prescribed prior to purchase by a participating provider, including retail pharmacists, working within their scope of practice; or
presented with a valid member claim form describing services listed in subsection (a) of this section and proof of purchase. A retail receipt shall be acceptable proof of purchase.

Limitation. Coverage of SARS-CoV-2 antigen testing under subsection (a) of this section shall be limited to eight (8) test kits of no more than two (2) tests each per covered life per month. Members may obtain tests on behalf of dependents. Tests shall be for at home personal use and not for resale.

Section 4.        Claims Retroactivity.

Health insurers shall process and reimburse appropriate claims for services described in this Emergency Rule retroactively to a date no later than December 1, 2021.

Section 5.        Severability.

If any provision of this emergency rule or the application thereof to any person or circumstance is for any reason held to be invalid, the remainder of the rule and the application of such provisions to other persons or circumstances shall be not affected thereby.

Section 6.        Conflict with Federal Law.

Nothing in this emergency rule is intended to or should be construed to be in conflict with federal law.

Section 7.        Effective Dates.

This emergency rule shall become effective on adoption and, pursuant to the authority granted in Act 6 of 2021 (§ 8), shall remain in effect until March 31, 2022.