Shipping Costs for At-Home COVID-19 Tests

Can a plan charge a participant for shipping/handling as part of its direct-to-consumer COVID-19 shipping option and stay within the safe harbor so that it can limit reimbursement to $12 for at-home tests purchased out-of-network?

One of the large (largest?) PBMs is currently stating that is the case.  To me, that doesn't seem to be within the spirit if not the letter of the current FAQs.  I haven't seen any guidance on that, either in the at-home test realm or even in the pre-COVID-19 general preventative care arena.

Regardless of the answer to the above, can a plan charge (e.g., not reimburse) a participant for the cost of expedited shipping, if the participant requests it?  That seems more defensible but I haven't seen any guidance on this either.

Thanks!

Great question.  I assumed that the direct-to-consumer shipping costs would have have to be covered.  I don't see how the PBM is reading "no upfront out-of-pocket expenditure" to permit an out-of-pocket expenditure for shipping.  What's next--refusing to cover taxes?

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf

For purposes of this safe harbor, direct coverage of OTC COVID-19 tests means that a participant, beneficiary, or enrollee is not required to seek reimbursement post-purchase; instead, the plan or issuer must make the systems and technology changes necessary to process the plan’s or issuer’s payment to the preferred pharmacy or retailer directly (including the direct-to-consumer shipping program) with no upfront out-of-pocket expenditure by the participant, beneficiary, or enrollee. 

I have a similar question.  What if a plan has not established a direct coverage arrangement (or an “adequate” direct coverage arrangement) and, as a result, can rely on the $12 reimbursement limit for eligible tests purchased from non-preferred pharmacy/retailer.  I’m this situation does the plan have to reimburse shipping costs for tests for these tests purchased at non-preferred pharmacies/retailers.

I am also aware of insurers/PBMs refusing to reimburse eligible tests obtained from “third party” sellers (e.g., Amazon, EBay, etc) because those tests are usually much more expensive due price gouging or supply/demand market influences.  I see the logic foe this and I see why it may be a defensible position, but I don’t see any support for it in the FAQs.

Tripp, on page 6 A2 of the FAQs Brian provided; No on $12, not sure about Shipping Cost as FAQs discuss cost of Test not other cost, like shipping,  I have seen an article about not having to pay Adminstrative Cost that some Pharmacies are tacking on.   See middle of the last paragraph:  

Specifically, a plan or issuer that is unable to meet the requirements of this safe harbor could not deny coverage or impose cost sharing (including setting limits on the amount of reimbursement for OTC COVID19 tests) with respect to any OTC COVID-19 tests, obtained by participants, beneficiaries, or enrollees, that meet the statutory criteria under section 6001(a)(1) of the FFCRA during this period, including those purchased from non-preferred sellers

On 1/27/2022 at 12:18 PM, Brian Gilmore said:

Great question.  I assumed that the direct-to-consumer shipping costs would have have to be covered.  I don't see how the PBM is reading "no upfront out-of-pocket expenditure" to permit an out-of-pocket expenditure for shipping.  What's next--refusing to cover taxes?

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf

For purposes of this safe harbor, direct coverage of OTC COVID-19 tests means that a participant, beneficiary, or enrollee is not required to seek reimbursement post-purchase; instead, the plan or issuer must make the systems and technology changes necessary to process the plan’s or issuer’s payment to the preferred pharmacy or retailer directly (including the direct-to-consumer shipping program) with no upfront out-of-pocket expenditure by the participant, beneficiary, or enrollee. 

Chaz adn Brian, 

Per today's 2.4.22 Part 52 release https://www.dol.gov/agencies/ebsa/about-ebsa/our-activities/resource-center/faqs/aca-part-52    

Q1: Do plans and issuers have flexibility in how they establish a direct-to-consumer shipping program and direct coverage through an in-person network in order to qualify for the safe harbor established in FAQs Part 51, Q2?

When providing OTC COVID-19 tests through a direct-to-consumer shipping program, plans and issuers must cover reasonable shipping costs related to covered OTC COVID-19 tests in a manner consistent with other items or products provided by the plan or issuer via mail order.

Scott A. Davis

Not sure why the extra copies below, but I did click the + button

On 1/27/2022 at 9:04 AM, Chaz said:

Can a plan charge a participant for shipping/handling as part of its direct-to-consumer COVID-19 shipping option and stay within the safe harbor so that it can limit reimbursement to $12 for at-home tests purchased out-of-network?

One of the large (largest?) PBMs is currently stating that is the case.  To me, that doesn't seem to be within the spirit if not the letter of the current FAQs.  I haven't seen any guidance on that, either in the at-home test realm or even in the pre-COVID-19 general preventative care arena.

Regardless of the answer to the above, can a plan charge (e.g., not reimburse) a participant for the cost of expedited shipping, if the participant requests it?  That seems more defensible but I haven't seen any guidance on this either.

Thanks!

On 1/27/2022 at 12:18 PM, Brian Gilmore said:

Great question.  I assumed that the direct-to-consumer shipping costs would have have to be covered.  I don't see how the PBM is reading "no upfront out-of-pocket expenditure" to permit an out-of-pocket expenditure for shipping.  What's next--refusing to cover taxes?

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf

For purposes of this safe harbor, direct coverage of OTC COVID-19 tests means that a participant, beneficiary, or enrollee is not required to seek reimbursement post-purchase; instead, the plan or issuer must make the systems and technology changes necessary to process the plan’s or issuer’s payment to the preferred pharmacy or retailer directly (including the direct-to-consumer shipping program) with no upfront out-of-pocket expenditure by the participant, beneficiary, or enrollee. 

Thanks, Scott.  Yes, I spent some time this weekend scrutinizing FAQs Part 52.  It'll be interesting to see how the PBMs react to this guidance.