The Biden administration is exploring ways for Medicare beneficiaries to get over-the-counter, at-home COVID-19 tests for free.
The White House is requiring private insurance companies to cover the cost of eight at-home COVID-19 tests per person each month, if the customer files for reimbursement. The requirement was put in place as a result of the massive surge in infections due to the omicron variant.
But the policy doesn't apply to Medicare beneficiaries, and the exclusion of 64 million older and disabled Americans has triggered a backlash.
Dozens of Democratic lawmakers and advocates have pressed the administration in recent days to change the rules, but the options to do so are limited, as Medicare typically doesn't cover home-use diagnostic tests.
"I am disappointed that the reimbursement option for eight additional at-home tests per month per person only applies to those with private or group health insurance," Rep. Anna Eshoo (D-Calif.) wrote to Health and Human Services (HHS) Secretary Xavier Becerra.
"Without comparable benefits available through Medicare, more than 18 percent of our nation's population will be made to pay out-of-pocket for additional at-home COVID-19 tests. Americans enrolled in Medicare are among the most susceptible and vulnerable to infection, so it's paramount that this population is given priority access to critical testing measures," Eshoo wrote.
Currently, traditional Medicare only pays for COVID-19 diagnostic tests performed by a laboratory, such as PCR and antigen tests. If the test is ordered by a physician, pharmacist or "authorized health care professional," there's no cost to the beneficiary.
Biden health officials said they are working nonstop to find a way to solve the issue.
"Over-the-counter tests have not been paid for as a Medicare benefit, but we're going through the process now to explore options and work through statutory and regulatory issues as we drive toward solutions," Meena Seshamani, director of the Center for Medicare and deputy administrator of the Centers for Medicare and Medicaid Services said in a statement to The Hill.
"We recognize testing remains a critical tool to help mitigate the spread of COVID-19, and we are committed to providing resources to keep Medicare beneficiaries safe and healthy," Seshamani added.
During a recent briefing, White House coronavirus task force coordinator Jeff Zients noted that Medicare beneficiaries already have access to free testing at tens of thousands of free-standing sites nationwide.
The administration is also providing 50 million testing kits to thousands of community health centers and Medicare-certified rural health clinics for distribution to patients and community members.
Beneficiaries can also order four tests per household from the federal website CovidTests.gov and have them shipped by the U.S. Postal Service.
Medicare Advantage, where beneficiaries join private managed care plans, is also a possibility, though each company sets its own rules and coverage varies.
Older adults are most at-risk of severe complications from COVID-19, and expanding their access to tests could slow transmission. And as new treatments are developed that require early intervention, at-home tests are becoming even more important.
Advocates and lawmakers said HHS has issued waivers and emergency rules for other Medicare policies during the pandemic, and should be flexible with coverage of at-home tests as well.
"Seniors and people with disabilities enrolled in Medicare are at the highest risk of severe illness from COVID-19, and people over 65 account for nearly three-quarters of all deaths from the virus. The current policy leaves them on the hook for potentially significant out-of-pocket costs," a group of 19 Senate Democrats, led by Rep. Debbie Stabenow (D-Mich.), wrote in a letter to HHS.
Casey Schwarz, senior counsel at the Medicare Rights Center, said the available options for seniors can be burdensome.
"Lab testing for COVID is covered as many times as your provider orders it, which means that you need to contact your primary care provider, and then explain why you need a test ... and then they need to order it, and then you need to go to the testing site they ordered it at. All of these steps can increase the barriers," Schwarz said.
Schwarz said Medicare coverage is determined by statute, and changing it is not easy. The absolute simplest way is congressional action, but she said the administration shouldn't wait for lawmakers, because it may not happen quickly, or at all.
The administration has some authority to waive certain Medicare requirements under the current public health emergency, but she said "the exact parameters of that authority are subject to some interpretation."
"There's no real sound policy reason that this population should be without insurance coverage for tests. It's a product of how Medicare is designed," Schwarz said.
The other problem is that Medicare isn't set up to simply reimburse beneficiaries who purchase tests like private insurance does. Medicare pays providers, not individuals.
"So there's some logistical matters that are somewhat unique to Medicare. For the immediate term, that's the hard part- figuring out, is there a way to do it under existing law?" said Jack Hoadley, a research professor emeritus at Georgetown University.
While the administration assesses its options, Schwarz said Medicare in the interim should expand coverage for lab tests so they can be more accessible.
"There are some things that might be easier and some things that might be harder," Schwarz said. "Getting to the point where everyone with Medicare can go can order a test online and submit a receipt for reimbursement? I think that's pretty hard. Expanding coverage in some way? That seems more doable."