Why Medicare Doesn’t Pay for Rapid At-Home Covid Tests

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[UPDATED at 4 p.m. ET]

What group is very susceptible to the ravages of covid-19 even when absolutely vaccinated and boosted? Seniors. And who may have an particularly powerful time getting free at-home covid exams below the Biden administration’s plan? Sure, seniors.

As of Jan. 15, personal insurers will cowl the price of eight at-home speedy covid exams every month for his or her members — for so long as the general public well being emergency lasts.

Discovering the exams will probably be onerous sufficient, however Medicare beneficiaries face a good greater hurdle: The administration’s new rule doesn’t apply to them.

It seems that the legal guidelines governing conventional Medicare don’t present for protection of self-administered diagnostic exams, which is exactly what the speedy antigen exams are and why they’re an necessary software for holding the pandemic.

“Whereas at the moment unique Medicare can’t pay for at-home exams, testing stays a crucial software to assist mitigate the unfold of covid,” a press release from the federal Facilities for Medicare & Medicaid Providers mentioned. Medicaid and CHIP cowl at-home covid exams, with no price to beneficiaries, primarily based on a 2021 Biden administration mandate.

Medicare sufferers are left to hunt free exams different methods, together with by way of the administration’s new web site, covidtests.gov, and at neighborhood facilities. The Medicare program does cowl speedy antigen or PCR testing accomplished by a lab with out charging beneficiaries, however there’s a hitch: It’s restricted to 1 check per yr except somebody has a health care provider’s order.

Extra must be accomplished, advocates say.

The administration has modified some Medicare guidelines through the pandemic, together with enhancing entry to telehealth providers and nursing residence care, mentioned David Lipschutz, affiliate director and senior coverage lawyer on the Middle for Medicare Advocacy.

“We all know that the Medicare program has important flexibility relative to the general public well being emergency, and it has demonstrated it has the flexibility to change the principles,” Lipschutz mentioned. “We predict they need to discover the pliability to supply the covid at-home exams free of charge.”

Q: Why can’t the Medicare program reimburse beneficiaries for the over-the-counter exams or decide up the tab on the pharmacy as industrial well being plans will do?

The providers the Medicare program pays for are spelled out in federal regulation.

“It typically excludes over-the-counter issues,” mentioned Casey Schwarz, senior counsel for schooling and federal coverage on the Medicare Rights Middle, an advocacy group. 

The general public well being emergency was lately prolonged 90 days, by way of mid-April, and the administration may but determine to increase protection. Some lawmakers in Congress are urging the administration to cowl the exams.

“Demanding Medicare recipients — almost one-fifth the inhabitants of the USA — to foot the invoice out-of-pocket for at-home exams is unfair, inefficient, and can price lives,” mentioned Rep. Invoice Pascrell Jr. (D-N.Y.), who has urged the Biden administration to increase Medicare protection to incorporate them.

It will not be a easy change, as these exams seem to fall into protection gaps. Medicare Half A covers hospitalization, and Half B typically covers provider-based providers like physician visits and lab exams. Half D covers medication.

“So there’s somewhat little bit of a query of the place this kind of profit would match,” Schwarz mentioned.

Folks in personal plans typically pay upfront for providers after which are reimbursed by their well being plan. However that’s not how Medicare works. This system pays suppliers, not beneficiaries. In order that’s one other wrinkle that must be ironed out.

Q: So how can a Medicare beneficiary get free at-home covid exams?

There are a few choices. This week, the Biden administration launched a web site, covidtests.gov, the place anybody, together with Medicare beneficiaries, can order free at-home covid exams. One billion exams finally will probably be obtainable. Every residence initially can obtain 4 exams.

4 exams is a far cry from the eight month-to-month exams that individuals with personal insurance coverage might be reimbursed for. Nevertheless it’s higher than nothing, specialists say, particularly when stopping the unfold of covid requires repeated testing over a interval of days.

“4 exams is just not lots of exams,” mentioned Juliette Cubanski, deputy director of this system on Medicare coverage at KFF. “This is among the most at-risk populations, and to not have the chance to purchase at-home exams and get reimbursed places this entire inhabitants on their again foot.”

The Biden administration can be offering as much as 50 million further free at-home exams to neighborhood well being facilities and Medicare-certified well being clinics.

However 50 million exams gained’t even present one check apiece to the 62 million Medicare beneficiaries, Lipschutz mentioned.

About 4 in 10 Medicare beneficiaries are in Medicare Benefit managed-care plans. These personal plans could provide free at-home exams to members, but it surely’s not required. Enrollees ought to test with their plans to see whether or not that’s an possibility.

Q: What different free covid testing choices can be found to Medicare beneficiaries?

In conventional Medicare, beneficiaries can get speedy antigen or PCR diagnostic exams with out paying something out-of-pocket if the check is ordered by a health care provider or different well being care supplier and carried out by a lab.

The federal authorities has arrange greater than 10,000 free pharmacy testing websites throughout the nation that Medicare beneficiaries can go to as properly.

With the latest extension of the general public well being emergency, the state of affairs is fluid, and Medicare beneficiaries could but get protection for at-home covid exams that’s corresponding to what privately insured folks now have.

“That is all a transferring goal,” Lipschutz mentioned.

[Update: This article was revised at 4 p.m. ET on Jan. 24, 2022, to include a comment from U.S. Rep. Bill Pascrell Jr.]

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