Minnesotans are finding plenty of gaps and footnotes in insurance providers' coverage for at-home COVID-19 tests.
The federal government now requires many private insurers to cover the cost of approved over-the-counter COVID tests, but most Medicare recipients in Minnesota are not eligible for the new benefit.
The federally mandated at-home testing benefit is open to everyone in employer-sponsored health plans, as well as all those with comprehensive coverage for individuals. But the rules and procedures vary by health insurer for how consumers can obtain a cost waiver at the point-of-sale or reimbursement later with proof of a sales receipt. And in some cases, the rules are still in flux.
Such permutations are on display across the nation. A Kaiser Family Foundation report this month found significant variation among insurers on whether they're offering consumers after-the-fact reimbursement or a "direct coverage" option — meaning a way to get tests with zero upfront, out-of-pocket costs.
"I think the complicated nature of this program reflects the complicated nature of the health care system more broadly in the U.S.," said Cynthia Cox, a vice president with the California-based foundation. "By relying on private insurers, that means that each company is going to do things a little bit differently and the patients or enrollees are the ones who are in the position of having to figure out how to navigate it all."
Starting Jan. 15, many people buying self-diagnostic COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA) could obtain them at no cost through a Biden Administration initiative.
Where it applies, health plans are required to pay for up to eight tests per person every month. When reimbursing consumers, carriers can cap their expenses at $12 per individual test, or $24 for a package that contains two tests. But that cap is only allowed if the insurer also provides its health plan enrollees with a direct coverage option as well, Cox said.
"If your plan has not set up a network of preferred stores, pharmacies, and online retailers at which you can obtain a test with no out-of-pocket expense, you will be reimbursed the amount of the cost of the test," the federal Centers for Medicare and Medicaid Services says in background materials. "For example, if you buy a two-pack of tests for $34, the plan or insurer would reimburse $34."
Some insurers are setting up preferred pharmacy locations where subscribers can receive direct coverage for the tests.
One wrinkle with most of these "preferred" or "network" arrangements is that consumers must visit the pharmacy counter and show their health plan ID card to avoid out-of-pocket costs. If they simply buy the tests at the store's main checkout, they will likely need to seek reimbursement later.
Minnetonka-based UnitedHealthcare, which is the nation's largest health insurer, announced this month preferred pharmacy relationships with Walmart and other retailers.
During a call with investors this month, executives at parent company UnitedHealth Group said the insurer scrambled to quickly implement the required benefit, for which the government only provided detailed guidance a few weeks ago.
Apparently, the kinks are still being worked out.
A Walmart worker said she hadn't heard of the direct coverage option on Monday evening when a Star Tribune reporter presented a stack of at-home tests and his UnitedHealthcare ID card at the pharmacy counter. After being shown information on the UnitedHealthcare website, the worker called over a pharmacist who said it would take 20 minutes to process the purchase.
"This appears to be an isolated incident," a Walmart spokesperson said in an e-mail, "and we will work hard to make sure it doesn't happen again."
The details still seem uncertain with other health plans, as well.
On Tuesday afternoon, Bloomington-based HealthPartners said it still hadn't finalized plans for a direct coverage option. It was also working on its process for providing reimbursements. The health insurer is asking subscribers with individual and employer-based coverage to save their receipts and details about the specific at-home test they used so they can submit for reimbursement once the process is in place.
People with individual coverage at Minneapolis-based UCare can get direct coverage for tests if they show their health plan ID card at the pharmacy counter of an in-network pharmacy.
Eagan-based Blue Cross and Blue Shield of Minnesota and Minnetonka-based Medica also provide direct coverage through their network pharmacies.
Consumers who pay out-of-pocket for tests elsewhere, such as from an online retailer, will usually need to fill out a claims reimbursement form. This works differently at each of the carriers.
At UCare, for example, enrollees are asked to complete a form provided by the insurer's pharmaceutical benefits manager (PBM). But the form was designed for covering the cost of medications, not tests. On it, enrollees are asked to list an "NDC code" — which is 10-digit or 11-digit number used to identify medications — along with the name of their doctor and the prescription number.
"We are working with [the PBM] to develop an OTC test-specific form that we hope will be available this week," UCare said via e-mail on Monday. "We will work with members on any reimbursement-related issues/questions while we wait for the new form to be developed and posted."
UCare is one the state's largest providers of Medicare Advantage health plans for seniors. For now, the company is only providing the at-home testing benefit to people with individual market coverage — not seniors in Medicare.
The free testing benefit also is not being provided by many other Medicare Advantage plans in Minnesota, including those from Blue Cross, Medica and UnitedHealthcare.
Those with original Medicare don't have the new benefit, but anyone can seek free at-home tests directly from the federal government.
"I think that if the Biden Administration felt like they had legal authority to extend this policy to Medicare they would have done that," said Cox of the Kaiser Family Foundation.
How long will it take to get reimbursed? Some plans say it all depends on how many people seek coverage — standard turnaround times can range from 10 to 30 days. The details can vary on what consumers will need to submit and whether claims should be submitted online or by mail or fax.
In all cases, health plan enrollees should call the member services number on the back of their insurance cards to learn all details.
"The complicated nature of it also reflects the speed at which the program is being rolled out," Cox said. "Over time, we might see insurers converge to have a more unified approach to this. But, at least initially, several insurers were not in a position to set up direct coverage the way that other insurers were."
COVID-19 tests still are being offered through state-run testing centers, clinics and pharmacies across the state. The Minnesota Department of Health also offers free at-home PCR tests by mail in collaboration with Vault Medical Services. Find a testing site and more info at mn.gov/covid19.
