Who’s eligible?

Medicare will cover these tests if you have Part B, including those enrolled in a Medicare Advantage plan.

If you are in a Medicare Advantage plan, the tests covered under this initiative will be covered outside of your existing plan’s coverage, and in addition to any over-the-counter tests that may be covered under the plan as a supplemental benefit.

Medicare won’t cover over-the-counter COVID-19 tests if you only have Medicare Part A (Hospital Insurance) coverage, but you may be able to get free tests through other programs.

When does this initiative start?

It starts April 4, 2022, and continues until the COVID-19 public health emergency (PHE) ends. People with Medicare Part B can get up to eight free over-the-counter tests for the month of April any time before April 30, and can then get another set of eight free over-the-counter tests during each subsequent calendar month through the end of the COVID-19 PHE.

How can I get tests through this initiative?

You can get over-the-counter COVID-19 tests at any pharmacy or health care provider that participates in this initiative. Check with your pharmacy or health care provider to see if they are participating.  If so, they can provide your tests and will bill Medicare on your behalf. A partial list of participating pharmacies can be found at https://www.medicare.gov/medicare-coronavirus.  You should bring your red, white, and blue Medicare card to get your free tests (even if you have a Medicare Advantage Plan or Medicare Part D plan), but the pharmacy may be able to get the information it needs to bill Medicare without the card. 

Do I have to change pharmacies to get a free test?

No. You can get your free over-the-counter COVID-19 tests from any eligible pharmacy or health care provider that voluntarily participates in this initiative, even if you aren’t a current customer or patient. Getting your tests won’t impact any prescriptions you have in place.

Will I have to pay anything to get over-the-counter COVID-19 tests in this initiative?

No, you won’t have to pay as long as you go to an eligible pharmacy or health care provider that participates in this initiative. However, if you get more than the eight covered over-the-counter COVID-19 tests in any calendar month, Medicare will not pay for additional over-the-counter tests in that month. You may be responsible for the cost of additional tests that calendar month, unless you have additional health coverage. If have additional coverage, you should check whether they will cover any additional tests obtained beyond the Medicare quantity limit. This means that the pharmacy or health care provider might ask you to pay for them. Note tests are sometimes packaged with more than one test per box, so eight tests may come in fewer than eight boxes.

Can I get reimbursed for any tests I bought before April 4, 2022?

No. Medicare coverage and payment begins on April 4, 2022, and is available for up to eight over-the-counter COVID-19 tests per calendar month you receive from a participating pharmacy or health care provider after the initiative starts. Medicare will not provide payment for over-the-counter COVID-19 tests obtained prior to April 4, 2022.

Do I have to wait a certain amount of time before I can get another eight over-the-counter tests through Medicare?

Starting April 4, 2022, this initiative covers up to eight over-the-counter COVID-19 tests each calendar month. If you’ve gotten eight of these tests in the current calendar month, you will need to wait until the beginning of the next calendar month to get more tests. For example, if you receive eight over-the-counter COVID-19 tests on April 14, 2022, through this initiative, you will not be eligible for another round of eight free over-the-counter COVID-19 tests until May 1, 2022. Note that there can be multiple tests per box, so eight tests may come in fewer than eight boxes.

Can I submit a claim for a test I pay for myself?

No. Medicare cannot process a claim submitted by a beneficiary for a COVID-19 over-the-counter test. You should check whether your pharmacy or health care provider is participating in the initiative, in which case they will bill Medicare for the over-the-counter test on your behalf.

When does this initiative end?

Medicare will pay for up to eight free over-the-counter COVID-19 tests per calendar month through this initiative as long as the COVID-19 PHE continues.

What other ways are there to get COVID-19 tests for you and your family??

• Order up to two sets of four at-home tests per household by visiting COVIDtests.gov.
• Get no-cost COVID-19 tests through health care providers at over 20,000 testing sites nationwide.
• Get PCR tests and antigen tests through a lab at no cost when a doctor or other health care professional orders it for you.
• During the COVID-19 PHE, get one lab-performed test without a health care professional’s order, at no cost.

Call 1-800-Medicare (1-800-633-4227) with any questions about this initiative. TTY users can call 1-877-486-2048.

Medicare also maintains several resources to help ensure beneficiaries receive the correct benefits while also avoiding the potential for fraud or scams. More details—particularly on identifying scams related to COVID-19—can be found at https://www.medicare.gov/basics/reporting-medicare-fraud-and-abuse.

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This is the first time that Medicare has covered an over-the-counter test at no cost to beneficiaries. There are a number of issues that have made it difficult to cover and pay for over-the-counter COVID-19 tests. However, given the importance of expanding access to testing, CMS has identified a pathway that will expand access to free over-the-counter testing for Medicare beneficiaries. This new initiative will enable payment from Medicare directly to participating pharmacies and other participating entities to allow Medicare beneficiaries to pick up tests at no cost. CMS anticipates that this option will be available to people with Medicare in the early spring.

Until then, people with Medicare can access free tests through a number of channels established by the Biden-Harris Administration. Medicare beneficiaries can:

• Request four free over-the-counter tests for home delivery at covidtests.gov.
• Access COVID-19 tests through healthcare providers at over 20,000 free testing sites nationwide. A list of community-based testing sites can be found here.
• Access lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost. In addition to accessing a COVID-19 lab test ordered by a health care professional, people with Medicare can also already access one lab-performed test without an order, also without cost sharing, during the public health emergency.

In addition:

• Medicare Advantage plans may offer coverage and payment for over-the-counter COVID-19 tests as a supplemental benefit in addition to covering Medicare Part A and Part B benefits, so Medicare beneficiaries covered by Medicare Advantage should check with their plan to see if it includes such a benefit.  
• All Medicare beneficiaries with Part B are eligible for the new benefit, whether enrolled in a Medicare Advantage plan or not.

For more information, please see these Frequently Asked Questions, https://www.cms.gov/files/document/covid-19-over-counter-otc-tests-medicare-frequently-asked-questions.pdf (PDF)

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CMS.gov | Contributed

As part of its ongoing efforts across many channels to expand Americans’ access to free testing, the Biden-Harris Administration is requiring insurance companies and group health plans to cover the cost of over-the-counter, at-home COVID-19 tests, so people with private health coverage can get them for free starting January 15th. The new coverage requirement means that most consumers with private health coverage can go online or to a pharmacy or store, buy a test, and either get it paid for up front by their health plan, or get reimbursed for the cost by submitting a claim to their plan. This requirement incentivizes insurers to cover these costs up front and ensures individuals do not need an order from their health care provider to access these tests for free.

Beginning January 15, 2022, individuals with private health insurance coverage or covered by a group health plan who purchase an over-the-counter COVID-19 diagnostic test authorized, cleared, or approved by the U.S. Food and Drug Administration (FDA) will be able to have those test costs covered by their plan or insurance. Insurance companies and health plans are required to cover 8 free over-the-counter at-home tests per covered individual per month. That means a family of four, all on the same plan, would be able to get up to 32 of these tests covered by their health plan per month. There is no limit on the number of tests, including at-home tests, that are covered if ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.

“Under President Biden’s leadership, we are requiring insurers and group health plans to make tests free for millions of Americans. This is all part of our overall strategy to ramp-up access to easy-to-use, at-home tests at no cost,” said HHS Secretary Xavier Becerra. “Since we took office, we have more than tripled the number of sites where people can get COVID-19 tests for free, and we’re also purchasing half a billion at-home, rapid tests to send for free to Americans who need them. By requiring private health plans to cover people’s at-home tests, we are further expanding Americans’ ability to get tests for free when they need them.”

Over-the-counter test purchases will be covered in the commercial market without the need for a health care provider’s order or individualized clinical assessment, and without any cost-sharing requirements such as deductibles, co-payments or coinsurance, prior authorization, or other medical management requirements.

As part of the requirement, the Administration is incentivizing insurers and group health plans to set up programs that allow people to get the over-the-counter tests directly through preferred pharmacies, retailers or other entities with no out-of-pocket costs. Insurers and plans would cover the costs upfront, eliminating the need for consumers to submit a claim for reimbursement. When plans and insurers make tests available for upfront coverage through preferred pharmacies or retailers, they are still required to reimburse tests purchased by consumers outside of that network, at a rate of up to $12 per individual test (or the cost of the test, if less than $12). For example, if an individual has a plan that offers direct coverage through their preferred pharmacy but that individual instead purchases tests through an online retailer, the plan is still required to reimburse them up to $12 per individual test. Consumers can find out more information from their plan about how their plan or insurer will cover over-the-counter tests.

“Testing is critically important to help reduce the spread of COVID-19, as well as to quickly diagnose COVID-19 so that it can be effectively treated. Today’s action further removes financial barriers and expands access to COVID-19 tests for millions of people,” said CMS Administrator Chiquita Brooks-LaSure.

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. In 2021, the Biden-Harris Administration issued guidance explaining that State Medicaid and Children’s Health Insurance Program (CHIP) programs must cover all types of FDA-authorized COVID-19 tests without cost sharing under CMS’s interpretation of the American Rescue Plan Act of 2019 (ARP). Medicare pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests, with no beneficiary cost sharing when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional. People enrolled in a Medicare Advantage plan should check with their plan to see if their plan offers coverage and payment for at-home over-the-counter COVID-19 tests.

This effort is in addition to a number of actions the Biden Administration is taking to expand access to testing for all Americans. The U.S. Department of Health and Human Services (HHS) is providing up to 50 million free, at-home tests to community health centers and Medicare-certified rural health clinics for distribution at no cost to patients and community members. The program is intended to ensure COVID-19 tests are made available to populations and settings in need of testing. HHS also has established more than 10,000 free community-based pharmacy testing sites around the country. To respond to the Omicron surge, HHS and FEMA are creating surge testing sites in states across the nation.

For more information, please see these Frequently Asked Questions, https://www.cms.gov/files/document/11022-faqs-otc-testing-guidance.pdf

For additional details on the requirements, visit https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf

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