Why doesn’t Medicare pay for COVID home tests?

What group is especially vulnerable to the ravages of covid, even if fully vaccinated and boosted? The older adults. Yet who will have a harder time getting free home tests for covid under the Biden administration’s plan? Yes, older adults.

Starting Jan. 15, people with private insurance can buy up to eight rapid home COVID tests a month, and their health plans must pay for them, for the duration of the public health emergency.

Finding either test is tough enough, but Medicare beneficiaries face an even bigger hurdle: The administration’s new rule doesn’t apply to them.

It turns out that the laws that govern Medicare do not provide coverage for self-administered diagnostic tests, which is precisely what rapid antigen tests are, and why they are an important tool in containing the pandemic.

“While at this time Original Medicare cannot pay for home testing, testing remains a critical tool to help mitigate the spread of COVID,” according to a statement from the Centers for Medicare & Medicaid Services (CMS). .

Basically, Medicare patients can find free tests in other ways, through the administration’s new website, covidtests.gov, and at community centers or county bookstores.

The Medicare program covers rapid antigen or PCR tests performed by a laboratory without charging beneficiaries, but here’s the problem: it is limited to one test per year unless you have a doctor’s order.

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More needs to be done, say advocates for older adults.

The administration has changed some Medicare rules during the pandemic, such as improving telehealth and home care services, said David Lipschutz, associate director and senior policy advocate at the Center for Medicare Advocacy.

“We know that the Medicare program has significant flexibility in relation to the public health emergency,” Lipshutz said. “We think they should find the flexibility to offer free home COVID testing.”

Here are some answers from experts.

Why can’t the Medicare program reimburse beneficiaries for over-the-counter tests or pay the bill at the pharmacy like commercial health plans do?

The services that the Medicare program pays for are listed in federal law and home diagnostic tests are not listed as a service.

“It typically excludes over-the-counter items,” said Casey Schwarz, senior adviser for education and federal policy at the Medicare Rights Center, an advocacy group.

The public health emergency was recently extended 90 days, through mid-April, so the administration could still determine it has the authority to expand coverage. Some lawmakers in Congress are reportedly urging the administration to cover up those tests.

It may not be a simple change, as tests seem to fall into coverage gaps. Medicare Part A covers hospital stays and Part B generally covers provider services, such as doctor visits and lab tests. Part D covers drugs.

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“So there are questions about where this kind of benefit would fit,” Schwarz said.

People in private plans sometimes pay for services up front and then get reimbursed by their health plan. But Medicare doesn’t work like that. The program pays providers, not beneficiaries. That is another difficulty that should be resolved.

So how can a Medicare beneficiary get free home tests for covid?

There are a couple of options. The Biden administration launched covidtests.gov, where anyone, including Medicare beneficiaries, can request free at-home tests for covid. Eventually, a billion tests will be available. Each residence can initially receive four tests.

Four tests is a far cry from the eight a month that people with private insurance can be reimbursed for, but it’s better than nothing, experts say, especially when preventing the spread of Covid requires repeat tests over a period of days.

“Four tests is not a lot of tests,” said Juliette Cubanski, deputy director of the Medicare policy program at KFF. “This is one of the most at-risk populations, and not having the opportunity to purchase home tests and receive reimbursement puts this entire population at a disadvantage.”

The Biden administration is also providing up to 50 million additional free home tests to community health centers and Medicare-certified health clinics.

But 50 million tests won’t even provide a test for each of the 62 million Medicare beneficiaries, Lipschutz said.

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About four out of 10 Medicare beneficiaries are in Medicare Advantage managed care plans. These private plans may offer free at-home testing to members, but it is not required. Each member should check with their plan to see if they offer this option.

What other free covid testing options are available to Medicare beneficiaries?

In Original Medicare, you can get rapid antigen or PCR diagnostic tests at no out-of-pocket cost if the test is ordered by a doctor or other health care provider and performed by a laboratory.

The federal government has established more than 10,000 free pharmacy testing sites across the country that Medicare beneficiaries can also visit.

With the recent extension of the public health emergency, the situation is fluid and Medicare beneficiaries can still get coverage for home COVID tests that is comparable to what people with private insurance now have.

“This is all a moving target,” Lipschutz said.

KHN (Kaiser Health News) is the newsroom of KFF (Kaiser Family Foundation), which produces in-depth journalism on health issues. Along with Policy Analysis and Surveys, KHN is one of the three main programs of KFF. KFF is a nonprofit organization that provides health information to the nation.

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