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

Why Medicare Doesn’t Pay for Rapid At-Home Covid Tests 1

Yves here. This post describes how rigidities in Medicare, as in “home tests not allowed,” prevent the program from reimbursing Covid tests.

One must ask why no one in the Biden administration has tried to fudge a rule reinterpretation and get that through the regulatory approval process. That would take some months but is better than doing nothing and letting seniors suffer….unless, as cynics allege, that is part of the plan.

After the way Team Biden imposed its vax mandate rule on OSHA after OSHA had drafted a far-reaching set of workplace provisions that included a mask mandate, ventilation, and separation, one would think they could try an easier lift….particularly since it’s hard to see who if anyone would find it in their interest to challenge it.

Oh, but wash my mouth out. All of the private insurer providing Medicare Advantage plans would be upset about giving more benefits at the same cost. Fine. If the Biden Administration had any balls (clearly not, but that’s the point of going on), officials could make clear they made sure the press knew damned well which Medicare Advantage plans were out to harm senior by fighting access to tests that everyone else could get.

Forgive me if I engage in a mini-rant about Medicare. While if you’ve been on overpriced, high deductible Obamacare plans, Medicare looks like a big step up, it’s thin gruel for pretty much everyone else.

Let’s start with the scam called Medicare Advantage, where to get in theory lower premiums (my mother didn’t), you are in a narrow network and subject to HMO gatekeeping. Or Medicare Part D, which as Medicare.gov blandly warns, “Each plan can vary in cost and specific drugs covered.” As I infer from the comments of readers who need expensive meds, one has to research carefully to see if the needed Rx is included. And you have to recheck every year! 1

On top of that, consistent with the Covid home est example, Medicare not only is poor on workarounds, it actually impedes them. Two of many idiocies from my caring for my mother:

1. During a Covid wave, she was due for an annual exam. Her doctor could do a telemedicine visit but, not unreasonably, wanted a blood workup.

She had COPD, so Covid would be an even more certain death sentence for her than most old people. I did not want her to go into the huge outpatient clinic (remember in Alabama where even medical professionals in hospitals don’t mask well/at all) and get a blood draw (she could not wear a high quality mask; “normal” blood ox for her was 92 and that place always makes patients wait, so there was no possibility of a fast in and out).

But despite working on it for the better part of two months, including calling multiple home health agencies if they had any aides who were also licensed phlebotomists who could do the job, I got nowhere. Medicare does not allow home visits just for a blood draw, and the MD was unwilling to add other service needs to set up a limited course of nursing visits. Literally every agency that had nurses would not allow me to hire a nurse for just a blood draw, even though that was not a Medicare-covered service. They simply were not willing to see a Medicare patient unless they could bill to Medicare.

2. I had a variant of this problem when I tried hiring a physical therapist, not as a formal PT (as in working under an MD Rx) but to do some at home strength and basic balance work2 The reason for preferring a PT was trainers seldom deal with super feeble old people and would likely be unable to come up with a sufficiently basic regime (and yes, we needed an outside human; it was hard enough to get my mother to cooperate even then).

Again without belaboring details, despite considerable effort, it was pretty much impossible to get someone to train her at home. I did find a licensed PT who advertised himself at the local Jewish community center as doing at home programs…and as I feared, he couldn’t gear down to something basic enough. Everyone else was Medicare connected and would not take a patient outside the Medicare regime….even though there was no physician Rx and therefore no providing of a Medicare service.

After by sheer accident getting a very good set of PTs for my post surgery rehab, I embarrassed my mother’s physician into writing an Rx for physical therapy and getting the same team for her. But that took over a year.

Mind you, we were in the high class position of being able to throw some money at these problems, which is not the case for many Medicare patients.

But it appears the only solution to problems like that is to opt out of Medicare B via enrolling in a “concierge” practice. Here the price is $3000 a year, which included as many MD visits as you need, and unlimited nurse house calls, but not specialists not in their practice and not test. 75% of their patients were elderly, so it was a de facto gerontology practice. Since my mother even in her very aged condition had needed only 3 MD visits a year, this seemed like an awfully high cost just to get access to a nurse.

Outside a low labor cost state like Alabama, the rate or an old person to join a concierge practice in the rest of the US is likely to be higher.

And do not let me get started on how few MDs take Medicare in high cost locales. A friend who recently left NYC had none of his NYC doctors accepting Medicare, and none of my smaller roster do either.

By Michelle Andrews. Originally published at Kaiser Health News

What group is especially vulnerable to the ravages of covid-19 even if fully vaccinated and boosted? Seniors. And who will have an especially tough time getting free at-home covid tests under the Biden administration’s plan? Yes, seniors.

As of Jan. 15, private insurers will cover the cost of eight at-home rapid covid tests each month for their members — for as long as the public health emergency lasts.

Finding the tests will be hard 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 governing traditional Medicare don’t provide for coverage of self-administered diagnostic tests, which is precisely what the rapid antigen tests are and why they are an important tool for containing the pandemic.

“While at this time original Medicare cannot pay for at-home tests, testing remains a critical tool to help mitigate the spread of covid,” a statement from the federal Centers for Medicare & Medicaid Services said. Medicaid and CHIP cover at-home covid tests, with no cost to beneficiaries, based on a 2021 Biden administration mandate.

Medicare patients are left to seek free tests other ways, including through the administration’s new website, covidtests.gov, and at community centers. The Medicare program does cover rapid antigen or PCR testing done by a lab without charging beneficiaries, but there’s a hitch: It’s limited to one test per year unless someone has a doctor’s order.

More needs to be done, advocates say.

The administration has changed some Medicare rules during the pandemic, including improving access to telehealth services and nursing home care, said David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy.

“We know that the Medicare program has significant flexibility relative to the public health emergency, and it has demonstrated it has the ability to alter the rules,” Lipschutz said. “We think they should find the flexibility to offer the covid at-home tests for free.”

Q: Why can’t the Medicare program reimburse beneficiaries for the over-the-counter tests or pick up the tab at the pharmacy as commercial health plans will do?

The services the Medicare program pays for are spelled out in federal law.

“It generally excludes over-the-counter things,” said Casey Schwarz, senior counsel 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, and the administration could yet decide to expand coverage. Some lawmakers in Congress are urging the administration to cover the tests.

“Demanding Medicare recipients — nearly one-fifth the population of the United States — to foot the bill out-of-pocket for at-home tests is unfair, inefficient, and will cost lives,” said Rep. Bill Pascrell Jr. (D-N.Y.), who has urged the Biden administration to expand Medicare coverage to include them.

It may not be a simple change, as these tests appear to fall into coverage gaps. Medicare Part A covers hospitalization, and Part B generally covers provider-based services like doctor visits and lab tests. Part D covers drugs.

“So there’s a little bit of a question of where this type of benefit would fit,” Schwarz said.

People in private plans sometimes pay upfront for services and then are reimbursed by their health plan. But that’s not how Medicare works. The program pays providers, not beneficiaries. So that’s another wrinkle that would have to be ironed out.

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

There are a couple of options. This week, the Biden administration launched a website, covidtests.gov, where anyone, including Medicare beneficiaries, can order free at-home covid tests. One billion tests eventually will be available. Each residence initially can receive four tests.

Four tests is a far cry from the eight monthly tests 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 repeated testing over a period of days.

“Four tests is not a lot of tests,” said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. “This is one of the most at-risk populations, and to not have the opportunity to buy at-home tests and get reimbursed puts this whole population on their back foot.”

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

But 50 million tests won’t even provide one test apiece to the 62 million Medicare beneficiaries, Lipschutz said.

About 4 in 10 Medicare beneficiaries are in Medicare Advantage managed-care plans. These private plans may offer free at-home tests to members, but it’s not required. Enrollees should check with their plans to see whether that’s an option.

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

In traditional Medicare, beneficiaries can get rapid antigen or PCR diagnostic tests without paying anything out-of-pocket if the test is ordered by a doctor or other health care provider and performed by a lab.

The federal government has set up more than 10,000 free pharmacy testing sites across the country that Medicare beneficiaries can visit as well.

With the recent extension of the public health emergency, the situation is fluid, and Medicare beneficiaries may yet get coverage for at-home covid tests that’s comparable to what privately insured people now have.

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


From EHealth:

Medicare plans providing prescription drug coverage can select medications to include in their list of covered prescription drugs (called the formulary) and, with certain restrictions set by Medicare, change the formulary. A plan’s formulary may change at any time. You will receive notice from your plan when necessary.

Plans often change their formularies each year. Although the plan notifies you of changes, it’s generally a good idea to review your plan’s Annual Notice of Change mailed in early fall each year to see if your medications are on the formulary for the coming year and compare your current plan to others available where you live.

If you find out your stand-alone Medicare Part D Prescription Drug Plan or Medicare Advantage Prescription Drug plan is planning to stop covering your prescription drug, then it may be a good idea to switch to another Medicare plan with prescription drug coverage. Remember that even though all Medicare plans with prescription drug coverage must cover the same drug categories or classes, each plan can choose which specific medications to include in each category, so a different plan may offer the prescription drug you take.

2 Going within her plan would have required an orthopedist visit and imaging, which = Covid risk, plus her HMO would have resisted at home therapy and instead wanted her to use their outpatient facility. Aside from yet more Covid risk, I had seen the programs she had gotten there is the past. They were cookie cutter with at best 40% of what they gave her suited to her needs…and some exercises actually counterproductive.

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