Starting Saturday, new federal rules will require private insurers to cover the at-home coronavirus tests that Americans buy in pharmacies and other stores. The new system could, in theory, allow millions of consumers to pick up tests at thousands of locations without spending any money.
The reality, at least in the short term, is likely to be messier: Some insurers say it will probably take weeks to fully set up the system the White House envisions.
The new process will be hard, the insurers say, because over-the-counter coronavirus tests are different from the doctor’s visits and hospital stays they typically cover.
The tests do not currently have the type of billing codes that insurers use to process claims. Health plans rarely process retail receipts; instead they’ve built systems for digital claims with preset formats and long-established billing codes.
Because of this, some insurers plan to manage the rapid test claims manually at the start.
“This is taking things back to the olden days, where you’ll have a person throwing all these paper slips in a shoe box, and eventually stuffing it into an envelope and sending it off to a health insurer to decipher,” said Ceci Connolly, president and C.E.O. of the Alliance of Community Health Plans, which represents smaller, nonprofit insurers.
Ms. Connolly also criticized the implementation timeline as too rushed, with the government issuing rules on a Monday that are to take effect on a Saturday.
“It is going to be exceedingly difficult for most health plans to implement this in four days,” she said.
The challenges of insurers may soon trickle down to consumers, who will be responsible at first for navigating their health plans’ reimbursement rules to get their tests covered.
“There will be some people who buy them, and then have a six-month nightmare trying to get reimbursed,” said Jenny Chumbley Hogue, a Texas-based insurance broker. She has not yet seen a plan she works with that has sent out member guidance on how coverage will be handled.
Uncertain of what the rules will be, Ms. Hogue is advising her clients to save not just receipts but also the boxes that the tests come in, because some plans may require the boxes as proof of purchase.
Some public health experts have criticized the plan as unnecessarily complex, saying they would have preferred the Biden administration to provide free kits directly to patients.
“The direct provision of inexpensive tests for the American public would be the simplest from a consumer standpoint,” Lindsey Dawson, an associate director at the Kaiser Family Foundation, previously told The New York Times. “Someone will need to know it’s reimbursable, navigate the reimbursement process, and front the cost to begin with.”
Other countries have spent more heavily on rapid testing. In Britain, citizens can use a government website to order free rapid tests for home use. Germany invested hundreds of millions of dollars to create a network of 15,000 rapid testing sites. The United States has instead focused public purchasing on vaccines, and efforts to encourage their uptake.
Some local governments in the United States have invested heavily in rapid testing to counter the latest wave of cases. Washington, which has experienced a substantial surge in virus cases, now allows residents to pick up four free rapid tests daily at libraries across the city.
The Biden administration has instead relied more heavily on tests delivered in doctor’s offices. Federal laws have required insurers to cover those at no cost to the patient since the early months of the pandemic.
The new rules require private insurers to cover eight at-home coronavirus tests for each person, every month. The rules will not apply retroactively to at-home tests that Americans have already purchased, and do not cover patients with public insurance such as Medicare and Medicaid.
Under the new rules, consumers who get tests at their health plan’s “preferred” location will have the costs covered upfront, meaning the patient will pay nothing out of pocket. What counts as a “preferred” location will vary from one plan to another, although many expect those facilities to be ones that are already in-network with a given insurer.
Consumers that go to an out-of-network store will need to submit receipts for reimbursement, and the plan will only have to pay $12 per test (or $24 for a kit with two tests). If the sticker price is higher, the patient will be responsible for the additional charges.
Health plans that do not designate a set of “preferred” locations will have to cover the full costs of test receipts that their members submit.
Test prices currently range from $17.98 for a pack of two to $49.99 for an individual test, according to research Ms. Dawson conducted last week.
Highmark Health, a nonprofit plan in Pennsylvania with around six million members, plans to create a network of “preferred” locations but will not have it ready by this Saturday.
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“The guidance came out Monday, and we started working on it immediately, but I don’t have a mechanism ready to go, Day 1, where you don’t have to pay upfront,” said Bob Wanovich, a Highmark vice president who works on provider contracting.
One challenge Mr. Wanovich and others described was that insurers typically do not cover over-the-counter items at the pharmacy, like a pregnancy test or a nonprescription medication.
“Retailers need to have a process to capture the right codes, and submit it, and we need to be able to accept it on our end,” he said. “These are the pieces that aren’t there yet.”
Until they set up that infrastructure — a process that could take weeks — Highmark Health will be advising patients to submit receipts along with a photograph of their test kit’s bar code for reimbursement.
Capital District Physicians’ Health Plan, a small insurer in upstate New York, plans to instruct members to hold on to their test receipts as it sorts out a system for processing them.
“We’re getting a ton of calls from consumers asking about it, so we’re trying to arm our member service staff with the right information,” said Ali Skinner, the plan’s vice president for communications.
Ms. Skinner said the insurer was still working to have “preferred” locations designated by Saturday, so patients could pick up tests without the reimbursement process, but she was uncertain about whether it would meet the deadline.
“We’re up against the clock right now,” she said. “It’s a big lift for us. We found out at the same time as consumers did on Monday.”
Even as insurers sort out systems for processing claims, they noted one major factor will remain out of their control: testing supply, and the shortages that consumers have confronted in recent weeks.
“The bigger frustration our members have is over finding a test, and I don’t have any control over the supply,” said Mr. Wanovich of Highmark Health. “We’re working with our providers to figure out who has them, but we know it’s in short supply.”