A bulletin in North Carolina says that “effective Jan.While state policy and bulletins are evolving, a number of states are using a standing order to allow Medicaid enrollees to obtain at-home tests from a retail pharmacy with no cost sharing. How are states implementing these rules?Īs with most rules for Medicaid, states have some discretion and flexibility in how they provide coverage and reimbursement for at-home tests so there may be variation across states in how easily enrollees can access at home tests. There is no mechanism in Medicaid to provide similar direct reimbursement to enrollees, so even if enrollees could afford to pay out of pocket, they could not recoup costs in the same way. Under the new federal rules, private insurance must reimburse for up to 8 tests per member per month, however, in many cases this may require individuals paying out of pocket and then filing for reimbursement from insurance. Given that Medicaid covers low-income individuals, Medicaid rules would allow individuals to access at-home COVID-19 tests without having to pay out of pocket and then seek reimbursement. The guidance also says that “as states establish utilization management techniques, including possible prescription conditions, they are encouraged to do so in ways that do not establish arbitrary barriers to accessing COVID-19 testing coverage, but that do facilitate linking the reimbursement of a covered test to an eligible Medicaid or CHIP beneficiary.” The guidance says that “all types of FDA-authorized COVID-19 tests must be covered under CMS’s interpretation of the ARP COVID-19 testing coverage requirements, including, for example, “point of care” or “home” tests that have been provided to a Medicaid or CHIP beneficiary by a qualified Medicaid or CHIP provider of COVID-19 tests.” It further indicates states have discretion to condition coverage of a home test on a prescription as part of their utilization management or apply medical necessity criteria. In August 2021, the Centers for Medicare and Medicaid Services (CMS) issued guidance about coverage and reimbursement of COVID-19 testing under the ARPA for Medicaid and CHIP. Recent press releases and FAQs note that in accordance with the American Rescue Plan Act (ARPA), State Medicaid and Children’s Health Insurance Program (CHIP) programs are currently required to cover FDA-authorized at-home COVID-19 tests without cost-sharing. What are the rules for Medicaid coverage of at-home tests? While there has been a lot of attention paid to coverage and reimbursement requirements for at-home tests for people with private insurance, there seems to be confusion about how Medicaid enrollees can access at-home COVID tests. Recent efforts include a new program that started January 18 th to allow every household to order 4 free at-home COVID-19 tests from increasing the number of COVID tests available to schools and community health centers standing up new federal free-testing centers and requiring private health insurers to cover the costs of at-home COVID tests. As COVID cases have surged across the United States due to the new Omicron variant, the Biden Administration has stepped up efforts to expand testing capacity including by making at-home COVID tests more available.
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