When the Biden administration began requiring insurers to pay for at-home coronavirus tests, it left out a group especially vulnerable to the virus. Medicare, the federal insurance system with 64 million older or disabled Americans, was not included in the order, and the absence has triggered a fusillade of complaints.

Members of Congress and advocates for older Americans have dispatched vehement letters to President Joe Biden and his health secretary in recent days, urging the administration to alter Medicare’s rules so that it will uniformly pay for the antigen tests consumers use at home. Meanwhile, thousands of people on Medicare have called a federal hotline about the tests, confused about what is covered.

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Under such pressure, officials inside the administration “are working around-the-clock, trying to figure out what is possible,” said Meena Seshamani, Medicare director at the Centers for Medicare and Medicaid Services (CMS).

Advocates contend that the agency, which has made it easier for people with Medicare to see doctors through telehealth during the pandemic, should be flexible about covering at-home tests, as well. But Medicare law does not make that simple. The fundamental obstacle is that the statute does not let the traditional version of Medicare – the insurance for nearly 6 in 10 people in the program – include over-the-counter health products, such as coronavirus rapid tests, among its benefits. Separate Medicare drug benefits are for prescriptions.

CMS is scrutinizing Medicare law, regulations and operations, trying to find a wrinkle that could make tests more accessible by expanding the program’s coverage or some other approach, Seshamani said in an interview.

“We are looking hard at where there is a path forward,” Seshamani said. She declined to predict whether a solution will be found or how quickly that could happen.

For now, most people with Medicare cannot buy at-home coronavirus tests from a pharmacy or order them online and be reimbursed for the cost.

They have certain options. If a patient has a doctor’s order, the program pays for at-home tests or PCR tests, in which a lab determines the results. And CMS sent a mass email to everyone on Medicare encouraging them to go to a federal website, CovidTests.gov, to order up to four free tests per household, to be shipped by the U.S. Postal Service, as the White House announced this month.

Medicare beneficiaries also may pick up free tests from about 20,000 community health centers and rural clinics to which the federal government has distributed rapid-testing kits.

The options are not enough, advocates for older Americans say.

“They can go to a testing site, when it may be dangerous for them to leave home. They may not have transportation,” said Natalie Kean, a senior staff attorney for Justice in Aging, a legal group fighting poverty among older Americans. And most people on Medicare, she said, do not tend to rely on community clinics.

“Don’t only make it available to those with commercial insurance. It’s prejudicial,” said Astrid Homan, who lives in Imperial, Mo., about 40 minutes south of St. Louis. Single and 62, Homan has been on Medicare for nine years because of disabilities. She has narcolepsy, a neurological disorder involving sleep, and another nerve disorder that causes pain in her right leg, making it difficult to stand.

Homan is fully vaccinated and boosted against the coronavirus. She doesn’t go out much – mainly to the grocery store or the Walmart and to visit her mother, who will turn 90 next month, in a St. Louis retirement community. Homan was singing soprano in her church choir once it resumed, but the group decided it needed to stop again after Christmas as omicron spread.

She had a coronavirus test once, after attending a reception about a month ago for a friend’s ordination at a different church. Only after the reception did she learn that someone there had the virus. She called her doctor, who wrote an order for her to get a PCR test at a lab. She was negative.

She would like to be able to take tests more often, especially if she has been out before seeing her mother. A pharmacy she called told her the price was $79 for a combined coronavirus and flu test – more than she could afford. She lives on a $1,600 monthly Social Security check and a $600 ceiling on what federal disability rules let her earn each month from part-time work at home translating between English and her native Dutch. Sometimes, she has big bills for medicine.

Homan had heard that two public libraries were giving away at-home tests. Then she heard a county official on the radio, apologizing because the libraries with besieged with people who had hoped to get the limited supply.

This week, picking up something for her mother, she was standing in a checkout line next to a man who, she said was “coughing and hacking” while not wearing a mask. She wished she could take a test. “I’m not a nervous Nellie,” she said, “but I need to take every precaution I can.”

Such difficulty getting tests, advocates say, is particularly worrisome because older people are at high risk of becoming seriously ill or dying if infected with the coronavirus.

In the United States, 550,000 people 65 and older – the main age group for Medicare – have died of covid-19. They account for two-thirds of the coronavirus deaths, even though that age group represents 16.5 percent of the U.S. population, according to the Centers for Disease Control and Prevention. People 65 and older are hospitalized with covid at nearly three times the national average rate, CDC data show.

And paying for tests is burdensome for the many people on Medicare who have modest means. In 2019, the year before the pandemic, half of all people with Medicare had incomes below about $30,000, while 1 in 4 had incomes below $17,000, according to an analysis by the Kaiser Family Foundation, a health-care policy organization.

“Older Americans are aware of what’s going on with covid. They’ve been hit hard by it. They know the statistics, and there’s demand for tests,” said Andrew Scholnick, a senior legislative representative for AARP, the large advocacy organization for Americans 50 and older.

“Even a $12 test or $24 for a two-pack may not seem like a lot, but if they are being asked to do it every time they see their grandkids or go to a community center, it adds up,” Scholnick said.

The complaints from people with Medicare – and their advocates and congressional representatives – have percolated since the president announced this month that, as of Jan. 15, insurers must cover as many as eight free at-home coronavirus tests a month for other people with private health plans, either paying up front or reimbursing them afterward.

While the discontent is recent, the coverage rules in Medicare have been the same since the Food and Drug Administration first approved a coronavirus antigen test on an emergency basis in spring 2020, a few months into the pandemic.

Medicare, created in the 1960s as part of President Lyndon B. Johnson’s Great Society, is now divided into two parts – a traditional version in which the program covers each medical service – and a newer version known as Medicare Advantage, in which people join private managed care plans. The rules for covering coronavirus tests differ.

It is traditional Medicare that fails to cover coronavirus tests, unless ordered by a doctor or other health-care practitioner.

Under Medicare Advantage, with almost 28 million beneficiaries, each company decides whether to cover at-home tests. The result is a patchwork.

Kaiser Permanente, enrolling 1.7 million Medicare members, provides that coverage “in keeping with our long-standing commitment to equity,” the company said in an email.

UnitedHealthcare has more than 7 million people on Medicare – the most of any private insurer. A UnitedHealthcare spokeswoman, Tracey Lempner, said 85 percent of its Medicare Advantage plans contain a benefit for over-the-counter products or services and that people “may be able to get” at-home tests through the benefit. The company’s website, however, says that Medicare Advantage members are not reimbursed for at-home coronavirus tests unless they have a doctor’s order. Asked about the discrepancy, Lempner said the tests would be covered without a doctor’s order up to an unspecified amount spelled out in individual plans.

Humana – with nearly 5 million members on Medicare, second highest among private insurers – did not reply to questions about its coverage rules. But in its own canvass of insurers, the Kaiser Family Foundation found that Humana does not cover at-home coronavirus tests for those members, even if their Medicare Advantage plan includes some over-the-counter benefits for other products.

Aetna, owned by CVS Health and enrolling nearly 3 million people on Medicare, says on its website that it does not cover at-home tests for those members. The Blue Cross Blue Shield Association, representing nonprofit and for-profit health plans around the country with nearly 4 million Medicare enrollees, said in an email that those companies “are assessing the feasibility of what could be done for Medicare Advantage members.”

In giving managed care plans a choice, and not covering tests in traditional Medicare, Congress has treated the program differently than the private insurance industry and other public insurance overseen by CMS. The first two coronavirus relief laws, adopted in March 2020, when the pandemic was new, require insurance carriers that sell group or individual plans to cover coronavirus tests and treatment, at no cost to consumers as long as the country remains under a federal public health emergency.

Last year, the American Rescue Plan law said that Medicaid, the public insurance for the poor, and the Children’s Health Insurance Program, for youngsters from working-class families, must cover at-home coronavirus tests authorized by the FDA without any charge to the consumers.

Neither law mentioned Medicare.

“This should have been spelled out in the original legislation, which it was not,” said Rep. Bill Pascrell Jr., D-N.J., who began to hear complaints from constituents with Medicare late last year. “This is a glaring hole in our national policy,” he said in an interview.

This month, after Biden announced that insurers must pay for as many as eight tests per person each month for Americans with private coverage, Pascrell and Rep. Scott Peters, D-Calif., sent the president a letter, urging the administration to “close the gap.” It was the first of several letters from Capitol Hill. They included a letter two days later to Health and Human Services Department Secretary Xavier Becerra from Reps. Tom Malinowski, D-N.J., and Kim Schrier, D-Wash., and a bipartisan group of more than 100 other House members, followed by another letter to Becerra this week from Sen. Debbie Stabenow (Mich.) that was co-signed by 18 fellow Senate Democrats.

Three days after Pascrell and Peters wrote, White House press secretary Jen Psaki was asked why Medicare does not always pay for the tests. Psaki replied that the administration is “exploring a range of options.” She did not elaborate.

In the interview, Seshamani, the Medicare director, said officials are examining the law governing the program to see how laboratory tests and diagnostics are defined. They are studying the program’s regulations to figure out whether an over-the-counter test could fit into any of the agency’s guidance.

And they are thinking through logistics, including whether the pharmacies and other places that consumers buy coronavirus tests are enrolled in the program as Medicare providers, whether there is a diagnosis or procedure code they could use to submit claims for reimbursement, and whether the right kind of claims form exists.

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