Home Testing Kits Grow in Popularity But May Not Be Covered By the Health Plan

Home testing kits have proliferated in recent years, beginning with popular genetics services like 23andMe and Ancestry.com. As interest in home testing kits has grown, the market has exploded accordingly, with companies now offering home testing kits for a host of medical conditions like STDs, vitamin deficiencies, HIV, pregnancy, cholesterol, thyroid function and most recently…COVID-19.

As the public continues to embrace this technology, accuracy, appropriateness and costs have come under increased scrutiny from both government agencies and insurers. While the DGA-Producer Health Plan takes no position on the validity of specific home testing kits, Health Plan participants should know the circumstances under which these tests might be covered under the Health Plan.

The Health Plan covers Medically Necessary visits, treatments and procedures for you and your eligible dependents, including laboratory and diagnostic tests and services ordered by a physician to treat sickness or injury. All care must be Medically Necessary, excluding covered preventive care services, to be covered under the Health Plan.

When it comes to home testing kits, like all other testing—including testing for COVID-19—one important metric for determining whether the Health Plan might cover it, is whether the test has been ordered by an attending licensed physician and was not ordered solely to satisfy curiosity of the participant or the participant’s physician, hospital, or other health care provider. The Health Plan considers a treatment, service or supply medically necessary when the treatment meets all of the following requirements:

  • Consistent with generally accepted medical practice within the medical community for the diagnosis or direct care of symptoms, sickness or injury of the patient, or for routine screening examination under wellness benefits, where and at the time the treatment, service or supply is rendered. The determination of “generally accepted medical practice” is the prerogative of the Health Plan through consultation with appropriate authoritative medical, surgical, or dental practitioners;
  • Ordered by the attending licensed physician (or, in the case of dental services, ordered by the dentist), and not solely for the convenience of the participant or the participant’s physician, hospital or other health care provider;
  • Consistent with professionally recognized standards of care in the medical community with respect to quality, frequency and duration; and
  • The most appropriate and cost-efficient treatment, service or supply that can be safely provided, at the most cost-efficient and medically appropriate site and level of service.

It is important to understand the definition of medical necessity before you purchase and use a home testing kit. Understanding this standard will help you avoid surprise costs for tests that are not covered. Unless the test meets all four of the aforementioned requirements, it will likely not be covered, leaving you to pay the cost out of pocket. For details about the medical necessary standard, refer the 2020 Health Plan Summary Plan Description, pages 114-115, and its updates or speak to a Participant Services Representative at (323) 866-2200, Ext. 401 or toll-free at (877) 866-2200, Ext. 401.