Medicaid is a joint federal and state program that provides health coverage to millions of Americans, including eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities. During the initial years of the COVID-19 pandemic, coverage for testing was broadly mandated and often provided without any out-of-pocket costs to the recipient. This widespread, no-cost access was largely a result of temporary federal legislation linked to the Public Health Emergency (PHE) declaration. Today, the landscape is more complex, as federal requirements ensuring uniform coverage are expiring and shifting control back to individual states. The current reality depends heavily on existing federal law, temporary extensions, and specific state-level decisions.
The Federal Requirement for Coverage
Congress acted swiftly at the beginning of the pandemic to ensure that Medicaid programs provided coverage for COVID-19 testing. The Families First Coronavirus Response Act (FFCRA), signed into law in March 2020, prohibited states from imposing any cost-sharing, such as copayments or deductibles, for diagnostic testing and related services for all Medicaid enrollees. The requirement for full coverage applied whether the beneficiary was enrolled in a managed care organization or a fee-for-service plan.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act further clarified and expanded the types of diagnostic tests states were required to cover. The federal mandate ensured states covered all U.S. Food and Drug Administration (FDA)-authorized COVID-19 tests, including those granted Emergency Use Authorization (EUA). The FFCRA also provided an option for states to extend coverage for COVID-19 testing to uninsured individuals who would not otherwise be eligible for Medicaid. For states that adopted this option, the federal government provided 100% of the funding for the costs of these tests and testing-related services.
Testing Types and Access Points
Medicaid coverage during the Public Health Emergency was comprehensive, encompassing both laboratory-based and at-home testing methods. Clinical tests, such as Polymerase Chain Reaction (PCR) tests and rapid antigen tests ordered by a healthcare provider, were covered at no cost under the federal mandate. This coverage included the associated visit to a physician’s office, clinic, or emergency department where the test was administered or ordered.
Coverage also extended to Over-the-Counter (OTC) at-home tests, a convenient method for self-screening. The American Rescue Plan Act (ARPA) of 2021 required state Medicaid programs to cover FDA-authorized at-home COVID-19 tests for full-benefit enrollees without cost-sharing. During the PHE, coverage was implemented by allowing beneficiaries to receive up to eight individual OTC tests per month, often dispensed through a pharmacy. This mechanism provided a clear pathway for Medicaid recipients to obtain testing kits for use outside of a clinical setting.
Impact of the Public Health Emergency Ending
The federal Public Health Emergency (PHE) declaration officially ended on May 11, 2023, marking a significant transition point for COVID-19 coverage. Although the PHE ended, the federal coverage mandate for Medicaid testing was not immediately terminated. Provisions within the American Rescue Plan Act extended the requirement for Medicaid and Children’s Health Insurance Program (CHIP) programs to cover COVID-19 testing and treatment without cost-sharing for a period beyond the PHE’s expiration.
The federal requirement for mandatory, no-cost coverage of COVID-19 testing is set to expire on September 30, 2024. Until this date, Medicaid must continue to cover all FDA-authorized COVID-19 tests, including both laboratory-based and at-home tests, for full-benefit enrollees with no out-of-pocket costs. After the September 2024 deadline, the mandatory federal coverage requirement ceases, transferring discretion to individual states. This shift means states will no longer be federally required to cover screening tests or OTC at-home tests.
Coverage for diagnostic testing, which is testing ordered by a provider to diagnose an infection in a symptomatic patient, will likely continue to be available for most Medicaid beneficiaries under existing medical necessity rules. However, coverage for asymptomatic screening and, notably, for OTC at-home tests, may become subject to state-specific rules and limitations. The coverage for uninsured individuals under the optional Medicaid eligibility group established by the FFCRA terminated immediately upon the end of the PHE in May 2023.
Understanding Cost-Sharing and State Variation
During the entire duration of the federal mandate, Medicaid programs were explicitly prohibited from imposing any cost-sharing for COVID-19 testing or testing-related services. This included not only the laboratory and OTC tests themselves but also the associated administrative and provider fees. The goal of this policy was to eliminate financial barriers and encourage widespread testing as a public health measure. This no-cost rule remains in effect until the end of the federal coverage extension on September 30, 2024.
Following the expiration of the federal mandate, states will have increased flexibility to determine their own coverage policies and financial requirements. After September 2024, a state could potentially choose to impose nominal cost-sharing on Medicaid enrollees for COVID-19 testing. While many states may elect to continue providing testing with no cost-sharing to maintain access, this choice is no longer guaranteed by federal law. Beneficiaries must check with their specific state Medicaid agency or managed care organization to understand the exact coverage and any potential out-of-pocket costs implemented after the federal extension ends.