Retired Army Capt. Michael Storm wanted to take advantage of a new federal plan that requires health insurers to pay for up to eight home coronavirus tests each month.
When the Tuscaloosa, Alabama, man last week tried to get the home tests from his local pharmacy, he learned what tens of millions of Americans soon will discover: His federal health insurance provider doesn’t cover over-the-counter tests.
Storm gets his health insurance through Tricare, a Department of Defense health care program that covers millions of active-duty and retired military families. The home tests also won’t be covered by Medicare, the nation’s health insurance program that covers more than 61 million mostly older Americans.
“My wife is a schoolteacher, and every time she steps in the classroom she could be exposed (to COVID-19),” said Storm, a veteran of Vietnam and both Iraq wars. “We wanted to have the tests in hand for our family, to keep us safe.”
The Biden administration’s mandate that began Jan. 15 calls for those with private health insurance to get a monthly allotment of free tests. Yet health experts say the ambitious federal plan to quickly extend home testing will be challenging because of the nation’s fragmented health care system.
“This is going to be helpful for a lot of people, but it is not the most efficient or easy process for anybody,” said Sabrina Corlette, founder and co-director of the Center on Health Insurance Reforms at Georgetown University. “It’s like the rest of our health care system – a very patchwork, gap-filled approach to trying to get a benefit to people.”
The insurance reimbursement is separate from the new federal website, CovidTests.gov, which allows Americans to order four free kits per address delivered by the U.S. Postal Service. For a family of four, those free tests would be used quickly if a household experienced a COVID-19 outbreak. The insurance-funded strategy allow people a continuous source of tests.
Federal officials acknowledge coverage gaps for some groups.
Meena Seshamani, a deputy administrator at the Centers for Medicare and Medicaid Services, said in a statement that the agency is “assessing any options to increase testing availability for seniors.”
“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,” Seshamani said.
‘On the hook’ for out-of-pocket costs
Medicare was not included in the home-test mandate because the Biden administration did not believe it had clear legal authority to pay for the over-the-counter tests, Corlette said.
A group of 19 senators, most of them Democrats, urged the Biden administration Monday to extend home-test coverage to Medicare. In a letter to U.S. Department of Health and Human Services and CMS officials, the lawmakers said Medicare recipients, most of them older Americans but also some people with disabilities, are at higher risk for COVID-19 complications, and the absence of home-test coverage “leaves them on the hook for potentially significant out-of-pocket costs.”
In addition to the four free tests per family through CovidTests.gov, Seshamani said, seniors have access to more than 20,000 free testing sites nationwide. Medicare recipients also can get free laboratory-based tests from doctors, clinics, pharmacists and other authorized testing sites.
Medicaid, the health program that covers more than 83 million low-income families and children through the Children’s Health Insurance Program, has allowed payments for tests since August. Medicaid’s coverage of home tests was authorized by the American Rescue Plan Act.
Still, Medicaid rules vary by state. For example, North Carolina covers four kits each month, while Massachusetts covers eight kits a month, according to a Kaiser Family Foundation analysis.
Many states are still trying to figure out details on how to smoothly implement the plan for Medicaid providers and beneficiaries, said Jack Rollins, director of federal policy at the National Association of Medicaid Directors.
One key difference from private insurers, Rollins said, is that Medicaid programs are not allowed to reimburse recipients who purchase the home tests. So state Medicaid programs are figuring out billing details for pharmacies and other test providers.
“The coverage requirement is there, it’s in place, it’s just how do we get the dollars to flow to the pharmacies or anywhere else these tests are provided,” Rollins said.
It’s unclear how many Medicaid enrollees have accessed the free home tests, said Robin Rudowitz, Kaiser Family Foundation’s director for the program on Medicaid and the uninsured
Even if state Medicaid programs have authorized the tests, “I’m not sure enrollees know that is an option for them,” Rudowitz said.
The Medicaid option became available this fall as retailers and online stores have been frequently out of home tests amid spiraling demand triggered by the delta and omicron coronavirus variants.
Medicaid recipients might be more likely to get home tests from community health centers and other distribution sites such as libraries, fire stations and public health departments, Rudowitz said.
When his home test purchase was denied at a pharmacy, Storm contacted a veterans group and discovered home-testing reimbursement does not apply to retirees like himself. He chose to purchase rapid antigen testing kits with his own money. He can afford to do so, but he worries about military families and older adults on Medicare who cannot.
He said he understands the importance of quickly rolling out a program as the omicron variant sweeps across the nation, but he said he would have preferred the federal government had first addressed coverage gaps.
“They should never have gone on national TV and put the program out until they had all the details worked out,” Storm said.
Share your story: Have you tried to get reimbursed through your health insurer? If so, how did it go? Please share your experience with health reporter Ken Alltucker at [email protected]
Ken Alltucker is on Twitter at @kalltucker, or can be emailed at [email protected]