Medicare coverage of OTC COVID-19 tests begins

Providers can get $12 per at-home test provided to a Medicare Part B beneficiary beginning Monday and for the duration of the COVID-19 public health emergency, the Centers for Medicare and Medicaid Services announced.

Beneficiaries are eligible for up to eight free at-home tests per calendar month. Medicare Advantage enrollees can get the eight free tests outside their existing plan’s coverage, as well as any additional tests their plan covers as a supplemental benefit.

The coverage will only apply to beneficiaries enrolled in Medicare Part B, which covers mostly outpatient care. More than 59 million people fall into the category, according to CMS. Beneficiaries with only Medicare hospital insurance, or Part A, are not eligible for at-home test coverage.

Free COVID-19 tests for Medicare beneficiaries will be available at participating pharmacies, including CVS, Costco Pharmacy, Walgreens and Walmart. The program is voluntary, and pharmacies and providers who do not participate can continue to sell over-the-counter tests, including to Part B enrollees.

Other eligible providers, like physicians, skilled nursing facilities and independent laboratories can provide the tests and bill Medicare. Medicare will not cover at-home tests when billed by providers who give the tests during an inpatient stay.

Participation begins when a provider submits a claim to Medicare for a test. No separate participation agreement is necessary.

Medicare will pay providers a fixed national rate of $12 per test. If a provider’s typical rate is less than $12 per test, Medicare will reimburse the lesser rate.

Claims will be processed in the order they’re submitted. Providers cannot use roster bills, a way to submit multiple claims at once, for at-home COVID tests. CMS cannot process claims submitted directly by beneficiaries for over-the-counter tests.

CMS advises providers only to give patients the tests when requested. The agency also said providers should keep good documentation of patients’ requests for tests. CMS may ask for the documentation, and if it’s not provided, the agency could recoup payment and take other administrative actions, according to a fact sheet.

Beneficiaries cannot be reimbursed for previously purchased tests.

CMS announced in February that it would cover at-home tests for Medicare beneficiaries after pressure from Capitol Hill and advocates for older Americans to rectify the fact that people on Medicare had scant access to free at-home COVID-19 tests. Private insurers have had to cover eight free at-home tests for enrollees since January. Some Medicare Advantage plans covered at-home COVID-19 tests but Medicare in general does not pay for over-the-counter health products.

“For the first time in its history, Medicare is paying for an over-the-counter test,” Deputy Administrator Dr. Meena Seshamani, director of the Center for Medicare at CMS, said in a news release. “[T]his initiative will significantly increase testing access for Americans most vulnerable to COVID-19 and will provide valuable information for future payment policy supporting accessible, comprehensive, person-centered health care.”

The agency used a Social Security Administration demonstration program authority to allow temporary coverage of at-home COVID-19 tests, CMS confirmed. It allows the agency to test payment models to see if they increase Medicare’s efficiency. Medicare’s hospice benefit began as a demonstration program under the authority.

Using a demonstration project was likely the path of least resistance to quickly covering at-home tests through Medicare, said Tricia Neuman, senior vice president of KFF and the organization’s executive director for its program on Medicare policy.

“In some ways, the Secretary’s hands are tied without a change in law, so there are not many alternatives. And this is a pandemic where people are getting sick and dying, and while the hospitalization rates and deaths are going down, there is a concern about spread still,” Neuman said.


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