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You are here: Home / Anderson On Health Insurance / Antigen testing and administrative burden

Antigen testing and administrative burden

by David Anderson|  January 11, 202210:02 am| 53 Comments

This post is in: Anderson On Health Insurance, COVID-19

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The Biden Administration now requires insurers for fully insured plans to reimburse individuals for up to eight tests per month.  Dr. Valerie Lewis of UNC makes an excellent point last night:

 

It’s good that insurance will now cover 8 home tests/month. It’s bad that this involves reimbursement (which is arduous). And much worse, ~28M Americans have no insurance (concentrated in states that didn’t expand Medicaid) so can’t get tests reimbursed. https://t.co/y9RVLmFub3

— Valerie A. Lewis, PhD (@valeriealewis) January 11, 2022

Reimbursement is an administrative burden nightmare. Receipts will be required. There may be requirements for prescriptions. Cash needs to be fronted and then payments will be received via check or direct deposit several weeks to months later.

This is an obstacle course that will lead to predictable and disparate fall-off from people either trying and failing to get reimbursed or looking at the obstacle course and saying “fuck it.” We know that administrative burden is most heavily borne by individuals with low incomes, complex lives, low education and likely to be heavily minoritized (in an international and American contexts). People like my wife and I who are overly educated professionals who are good at navigating complex bureaucracies because this is what we do for a living and have been trained to do for our entire lives will figure out how to get reimbursed. People earning $20,423 and have a kid at home because school is closed because seventy percent of the teachers are either sick, in isolation or on quarantine and whose boss is demanding that they come in for an extra overnight shift tomorrow are far more likely to not succeed in getting a $50 or $100 reimbursement check approved — if they could ever afford to front the $50 or $100 to buy a few boxes of tests.

Antigen testing is primarily intended to provide public externalities. There are a few treatments which are reliant upon early identification where the gains of an early positive test can be captured by the individual taking the test. However, the primary purpose for antigen testing is to identify people without symptoms early enough so that future chains of infection can be broken before other people are infected.

Reimbursement is an attempt by the government to pay for some of the externalities that we want and need to generate. However given the administrative burden, take-up will be fairly light and non-uniform.

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Reader Interactions

53Comments

  1. 1.

    Old School

    January 11, 2022 at 10:11 am

    Is there a better plan that the Biden administration could have easily implemented?

  2. 2.

    Another Scott

    January 11, 2022 at 10:11 am

    I have to assume this is an easily implemented stop-gap measure while they ramp up their website for people to request tests to be mailed, while they ramp up production, while they continue to work on better tests, and all the rest.

    Belts and suspenders/another layer of Swiss cheese/etc.

    Meanwhile, the Pentagon is cutting the amount of people allowed in the building to 25% of normal capacity.

    Cheers,
    Scott.

  3. 3.

    Baud

    January 11, 2022 at 10:11 am

    @Old School: There’s always a better plan on the Internet.

  4. 4.

    Betty Cracker

    January 11, 2022 at 10:14 am

    @Old School: Free tests for everyone. That’s a better plan.

  5. 5.

    Baud

    January 11, 2022 at 10:14 am

    @Betty Cracker: Easily implemented? That was the question.

  6. 6.

    Gin & Tonic

    January 11, 2022 at 10:18 am

    @Baud: If only there were a quasi-governmental agency in the business of delivering things to every home in the country.

  7. 7.

    Baud

    January 11, 2022 at 10:24 am

    @Gin & Tonic: So because the Post Office exists, there are no other hurdles?  I don’t know, but I don’t pretend to be a logistics expert.

  8. 8.

    Phylllis

    January 11, 2022 at 10:27 am

    @Betty Cracker:  This.

  9. 9.

    narya

    January 11, 2022 at 10:28 am

    As I said at the end of the last thread: FQHCs (community health centerrs) are soon going to be able to order lots of at-home tests. Free to health centers, free to patients! So folks who can’t afford to buy tests should check with their local health centers!

  10. 10.

    Betty Cracker

    January 11, 2022 at 10:29 am

    @Baud: Dave explained how reimbursement complicates uptake rather well, so that goes to the “easily implemented” question. Logistics is irrelevant since insurance companies aren’t going to be involved in delivering tests either.

  11. 11.

    sab

    January 11, 2022 at 10:34 am

    @Old School: My guess is no, or they would have done it. If you are forced to co-govern with an anti-government partner ( GQP) what you get is lots and lots of friction that interferes with smooth governance.

  12. 12.

    Baud

    January 11, 2022 at 10:39 am

    @Betty Cracker:

    Two different issues.  One is the logistics the administration has to deal with to implement a different policy vs. this policy, the other is the logistics involved in getting reimbursements under this policy.

    Implementing this policy may have been easy for the administration to do quickly, as opposed to the free test for everyone by mail proposal.  I don’t know, and everything I’ve seen about it is just conclusory statements about how much better it would be to have free tests by mail.

  13. 13.

    Yarrow

    January 11, 2022 at 10:41 am

    Reimbursements are a pain. I’m in the middle of dealing with a reimbursement issue for my dad. Been working on it since September. Took until just before Christmas for me to get all the documentation and make the required phone calls so I could understand what needed to be done. It’s going to take me a full day to do the actual work because I have to go through six months of EOBs, make copies of everything and match them up, which is why I haven’t got to it yet. Oh, and they also said mail it, don’t fax it, so I have to spend money to send it in. So many obstacles at every step. It’s easy to see why people wouldn’t do it.

  14. 14.

    Betty

    January 11, 2022 at 10:46 am

    The broken system remains broken because people who should know better refuse to deal with it. Infuriating.

  15. 15.

    Old School

    January 11, 2022 at 10:46 am

    @sab: That’s what I assume as well, but I was hoping David would chime in with whether a system other than reimbursements could have been implemented, but he seems to have not stuck around this morning.

  16. 16.

    TheOtherHank

    January 11, 2022 at 10:48 am

    Flashback to all the computer gear sales that were implemented via rebates. I hated those, and I hate this. Means testing and paperwork bullshit are ways to say you did a good thing without actually having to do the good thing. And then you get to act surprised when people think you didn’t make their life better.

  17. 17.

    Yarrow

    January 11, 2022 at 10:50 am

    Seems to me there could be some version of a “prescription” people could print or pick up at the pharmacy, which then would dispense their free Covid test. Most people know how to go to a pharmacy.  The pharmacies could just have a bunch of “prescriptions” that would have the code on them. The pharmacy has the person’s insurance information and they’d send it in that way.

  18. 18.

    Another Scott

    January 11, 2022 at 10:53 am

    KaiserHealthNews:

    White House Directs Private Insurers To Cover Most At-Home Covid Test Costs

    Under guidance issued by the Biden administration yesterday, providers must shoulder the costs for up to 8 rapid antigen tests per month starting Jan. 15. Insurers can work with preferred pharmacies or retailers to directly cover over-the-counter test kits or reimburse beneficiaries after purchase.

    (Emphasis added.)

    Presumably CVS-Caremark will do the former, and that would presumably pressure all the other pharmacies to do the same. We can hope anyway.

    We’ll see!

    Cheers,
    Scott.

  19. 19.

    Baud

    January 11, 2022 at 10:54 am

    @Another Scott:

    Right.  Plus there are a lot of mail order pharmacies that operate the same way.

  20. 20.

    daveNYC

    January 11, 2022 at 11:01 am

    Getting reimbursed for a COVID test is going to be as easy or hard as the insurance company wants it to be. I’m sure this will go swimmingly.
    Since the insurance companies will have to do work to process the reimbursement requests, I don’t think it’s beyond the realm of possibility for the administration to have required insurance companies to cover the costs of the tests up front instead of having the patients eat the cost and then fill out paperwork to get their money back.

  21. 21.

    Central Planning

    January 11, 2022 at 11:02 am

    Does anyone know if the 8 tests are 8 single tests or 4 boxes that have 2 tests each?

    Are the tests covered regardless of the type of insurance? I have a high deductible plan which just reset so I generally pay for all healthcare for a few months.

    Finally, are there places that accept unopened test kits? If I don’t need them, I’m happy to get them and donate them to a local charity. Maybe something like a homeless shelter.

  22. 22.

    daveNYC

    January 11, 2022 at 11:06 am

    @Another Scott: Would they though?  They’ll just do the math as to which process costs them less money and go with that.  And I’m pretty sure that covering the cost of tests at the time of purchase will be more expensive.

  23. 23.

    Phylllis

    January 11, 2022 at 11:10 am

    @daveNYC:  I believe the administration is providing incentives to providers to provide free tests up front. This FAQ has a lot of information.

  24. 24.

    Betty Cracker

    January 11, 2022 at 11:13 am

    @Baud: I think Dave is looking at it through the proper lens: public health outcomes. Poor uptake means worse outcomes. I don’t know whether it makes more sense to send tests via the PO, distribute them thru pharmacies, all of the above, etc. I also don’t know if it’s easier to wave a magic wand and require insurers to pay for tests or have the government eat the cost for everyone. Presumably the former since that’s what the admin chose to do? But at what cost?

    Maybe the best plan would be to distribute tests at no cost to everyone but ask people for their insurance info and chase down the providers later? Could be that one factor we haven’t discussed — that we could be on the hook for testing indefinitely as the virus mutates and new waves hit populations — comes into play here.

  25. 25.

    Baud

    January 11, 2022 at 11:16 am

    @Betty Cracker:

    So many questions.  Everyone is acting like this is the final plan, as opposed to something that can be done now.  Maybe it is. I haven’t seen that in writing though.

  26. 26.

    Lobo

    January 11, 2022 at 11:20 am

    1. What if I’m uninsured? Can I still get free at-home over-the-counter COVID-19 tests?

    The Biden-Harris Administration is purchasing 500 million over-the-counter at-home tests to be distributed for free to all Americans who want them, with the initial delivery starting in January 2022. There will be a website where Americans can request at-home tests for home delivery—for free. More information on this federal program is expected soon.

    People without insurance can also get free at-home test from some community health centers.

    In addition, the U.S. Department of Health and Human Services (HHS) is providing up to 50 million free, at-home tests to community health centers and Medicare-certified health clinics for distribution at no cost to patients and community members. The program is intended to ensure COVID-19 tests are made available to populations and settings in need of testing, especially populations at greatest risk from adverse outcomes related to COVID-19. As of December 21, 2021, all Health Resources and Services Administration (HRSA) -supported health centers (including look-alikes) and Medicare-certified rural health clinics are eligible to participate in the program after completing the on-boarding process. More information about this program is here.

    HHS also has established more than 10,000 free community-based pharmacy testing sites around the country.  To respond to the Omicron surge, the Department of Health and Human Services (HHS) and the Federal Emergency Management Agency (FEMA) are creating surge testing sites in states across the nation.

    Additional information about testing resources for people without insurance are available here: https://www.hhs.gov/coronavirus/covid-19-care-uninsured-individuals/index.html.

  27. 27.

    Baud

    January 11, 2022 at 11:22 am

    @Lobo: Thanks for the info.

  28. 28.

    HinTN

    January 11, 2022 at 11:26 am

    Two semi-related items:

    Tennessee refused Medicaid expansion yet the public health system provides free PCR tests first come first served at the county health department. (Yes, I know that’s time away from work, but it’s always something.)

    Rumor has it that the at-home kits don’t pick up Omicron. (Truth or fiction?)

    ETA:

    From @Lobo

    People without insurance can also get free at-home test from some community health centers.

    This is also true here.

  29. 29.

    Benw

    January 11, 2022 at 11:29 am

    @Betty Cracker: NYS DOH provided free at home test kits to our school district (and I assume to all districts in the state), one 2-pack per student. It’s obviously not comprehensive, but it’s an easy way of getting kits to families regardless of income, and no messing around with insurance/costs. A good example of a government plan to find ways to distribute kits at all income levels.

  30. 30.

    Another Scott

    January 11, 2022 at 11:29 am

    @daveNYC: Indeed, they’ll do what costs them the least money.  That’s why I think that CVS-Caremark will work with the federal government to do the paperwork up-front:

    “Uncle Sam, we project we’ll need (wild-assed guess) 200M tests over the next 6 months.  Here’s what it will cost us to give them out and keep track for audit purposes.  Please cut us a check and send the kits.  Thanks.”

    vs

    “Ms. Smith picks up 2 boxes of test at CVS.  Clerk refers Ms. Smith to web site for reimbursement by Caremark.  Caremark has to spin-up 50,000 servers on AWS because Ms. Smith is one of 10M other people trying to do the same thing at the same time.  Caremark has to hire 5,000 more network admins to make their systems more robust, hire additional paper processors for people who aren’t on the web, hire additional phone people to handle the extra call volume, etc., etc.”

    The choice seems to me to be an easy one.

    Just a guess though!

    Cheers,
    Scott.

  31. 31.

    Yarrow

    January 11, 2022 at 11:29 am

    @HinTN:  The at home tests don’t pick it up as well as they picked up previous variants, from reports I’ve read.

    In the UK people had symptoms consistent with Omicron, did the at home nasal swab tests and would come up negative. If they tested again but swabbed their throats they’d get a positive. Seems that Omicron is more concentrated in the throat than previous variants.

    I just heard a short bit about this on TV yesterday in a longer piece on Covid so I guess the word is getting out here.

  32. 32.

    daveNYC

    January 11, 2022 at 11:32 am

    1. Why would these companies be incentivized to cover the cost up front?

    If a plan or insurer sets up a network of convenient options such as pharmacies or retailers, including online retailers, in which individuals on their plans can get their tests’ cost covered up front (at the point of sale), then it is permitted to limit the per test reimbursement amount for retailers outside of that network. Specifically, if a plan or insurer establishes this type of direct coverage option, then the plan or insurer is permitted to limit the reimbursement for tests purchased outside of their network to $12 per test (or the actual price of the test, if less). Many commercially available at-home tests run about $12 or less per test.

    Workable for high population areas, low pop areas are going to be dependent on whatever online options there are.

    Rather amusing that it sets up a potential issue with in-network and out-of-network test purchases.  If your local CVS (or whoever is in the network) is out of tests, then the person can still be stuck with doing the reimbursement paperwork and possibly not getting the full amount they paid for the tests.

    I have to say it’s a very American solution.

  33. 33.

    Phylllis

    January 11, 2022 at 11:35 am

    @Benw: We just had a brief discussion about doing that in our district this morning. Going to present it to the superintendent this afternoon. It’s an allowable American Rescue Plan expenditure. The state health department also just sent out guidance that districts can accept home test results (with documentation).

  34. 34.

    Phylllis

    January 11, 2022 at 11:37 am

    @daveNYC: Because cutting out the insurance middleman would hurt their fee-fees.

  35. 35.

    gene108

    January 11, 2022 at 11:42 am

    I read something yesterday that insurance companies can reimburse pharmacies directly. Buy the COVID test online, from an approved pharmacy, and the pharmacy will get directly reimbursed by the insurance. You can go mail order or pickup in store.

    The problem with the rule will be with non-approved “out of network” stores, which will vary by insurance plan. There you have to file a claim to get your $12 per test kit reimbursed.

     

    @Betty Cracker:

    Free tests for everyone. That’s a better plan.

    That’s the only strategy that’ll get popular support.

    Problem is I ran a cross a tweet yesterday, where someone asked if Biden can do get insurers to pay for COVID tests, what else can he do that he’s not doing? I pointed out he can only do this regarding COVID tests, because of the FFCRA.

    I think there’s a conspiracy theory building that if he can do “x” regarding COVID, why can’t he eliminate student loan debt or medical debt.

  36. 36.

    daveNYC

    January 11, 2022 at 11:42 am

    @Another Scott: Your hypothetical reimbursement system seems rather optimistic.  Why would the insurance companies spend money to make it easier for their customers to get them to send them even more money.  Far easier to just require the customers to print out and fill in a complicated form at home, attached the required documentation, mail it in, and provide no additional personnel to handle those forms or provide support for people trying to fill them in.

  37. 37.

    p.a.

    January 11, 2022 at 11:47 am

    @Yarrow: One of A.L.’s covid post links from a few days ago had the same info, that home nasal antigen tests SEEM to be iffy.  I’m reminded of The Onion’s headline: National Science Foundation Discovers Science is Hard.

  38. 38.

    gene108

    January 11, 2022 at 11:57 am

    @daveNYC:

    Why would the insurance companies spend money to make it easier for their customers to get them to send them even more money. Far easier to just require the customers to print out and fill in a complicated form at home, attached the required documentation, mail it in, and provide no additional personnel to handle those forms or provide support for people trying to fill them in.

    Some federal, but mostly state laws, control what insurance companies can do in each state. Refusing to reimburse anything, by de facto creating a slow and complicated bureaucratic process may run afoul of state insurance laws, which could cause the insurer the ability to operate in that state.

    As much as it seems insurers do whatever they want, they are governed by specific laws for their industry.

  39. 39.

    Argiope

    January 11, 2022 at 12:21 pm

    @Baud: I recently ordered some tests by mail from ihealth Labs thanks to a commenter here, and while they showed up much faster than I though they would, they showed up in a mailbox in OH on a day that was 21F—below the storage conditions of the test (36F up to around 80, if memory serves).  I have yet to hear back from the company about whether they are still usable or likely to be accurate.  Sending test kits by mail might require insulated packaging that they don’t have together yet, at least for many climates in January.

  40. 40.

    Another Scott

    January 11, 2022 at 12:24 pm

    @daveNYC: In addition to what Germy gene108 said above, CVS-Caremark is a drugstore and a health insurance company.  They’re going to be pushing out the test kits – they know that.  They’re going to be paid by the government – they know that.  It makes sense for them minimize their costs for the process.  Plus, they’re in competition with other big drugstore chains, so they want to appear to be the good guys in this case (as surely someone will do the direct negotiation with Uncle Sam, so it might as well be them).

    This is different from arguing about who’s paying for Ms. Smith’s $20,000 RA medication.  There’s no wiggle-room for them with these COVID tests.

    That’s my understanding anyway.

    Cheers,
    Scott.

  41. 41.

    Benw

    January 11, 2022 at 12:24 pm

    @Phylllis: I like it, and it felt like one of many the ways the schools were in it together with the community, even though there’s a lot of bad actors/misinfo these days that are trying to wedge the schools and communities apart.

  42. 42.

    Phylllis

    January 11, 2022 at 12:27 pm

    @Benw: It’s the right thing to do in these parts, as we are rural, poor, and with lots of barriers to healthcare and transportation. It’s also a good ‘goodwill building’ activity, which doesn’t hurt.

  43. 43.

    Kent

    January 11, 2022 at 12:29 pm

    @Baud:@Gin & Tonic: So because the Post Office exists, there are no other hurdles?  I don’t know, but I don’t pretend to be a logistics expert.

    If the USPS just sent out hundreds of millions of tests to all Americans a very large percentage would just be tossed in the garbage.  The waste would be enormous.  And it doesn’t sound like we have tens of millions of spare tests to waste that way.

    A better distribution plan would be to have free tests available at many distribution points like clinics, pharmacies, libraries, police stations, post offices, etc.   Even then you need some way to prevent people from grabbing 50 of them at a pop.  It’s the McDonald’s ketchup packet problem.  So you end up working your way back towards this sort of system.

    I don’t have the solution.   But it isn’t a super easy and obvious problem to solve.

  44. 44.

    Tazj

    January 11, 2022 at 12:30 pm

    @Argiope: That’s interesting. I hadn’t thought of that.

    The county where I live is distributing free rapid tests this week at community centers. Some are walk-in and some drive through.
    I’m glad that some people are able to get free tests but I don’t want to forget those that don’t have access because of work, health or transportation issues. Maybe this is one reason they’re not being mailed out yet.

  45. 45.

    way2blue

    January 11, 2022 at 1:08 pm

    Hopefully, this is the first step in a multi-pronged approach.  Stockpiling antigen kits at schools seems an obvious prong.  Also having the government subsidize the cost upfront, so binaxNOW is not $23 for two, but say half that…

  46. 46.

    Mousebumples

    January 11, 2022 at 1:53 pm

    I was actually in a work meeting about implementation for this earlier today. (background – i work for a pharmacy benefits manager or PBM)

    My takeaway from that is that even if the pharmacy is able to bill for the OTC tests, pharmacy staff is underwater (prescriptions, vaccines, performing covid testing… And now this too??), so someone who wants tests may be waiting at their pharmacy for 30 minutes for the pharmacy to bill their insurance for reimbursement.

    Also, i think there’s a max reimbursement amount – eg $12/test. So if you buy a $30 test off Amazon, and submit for reimbursement, you might not get the full $30 back.

     

    Semi-related – i was able to order 2 packs of tests from my health insurance last month at no charge, to be shipped out. For Juicers, I’d suggest investigating that with your medical insurance, if you haven’t already.

  47. 47.

    ThresherK

    January 11, 2022 at 2:05 pm

    @gene108:I ran a cross a tweet yesterday, where someone asked “If Biden can do get insurers to pay for COVID tests, what else can he do that he’s not doing?”

    You also ran across the Rainbow-Farting Unicorn collective? They are tiresome and seldom ask things in good faith.

  48. 48.

    burnspbesq

    January 11, 2022 at 2:22 pm

    @Gin & Tonic: 

    So they can be stolen out of mailboxes and ransomed on eBay?

  49. 49.

    Tazj

    January 11, 2022 at 2:47 pm

    I just came across this article from PBS that came out January 7th that says rapid tests will be mailed out upon request after the first batch of tests are distributed to people.https://www.pbs.org/newshour/health/what-you-need-to-know-about-the-free-at-home-covid-tests-promised-by-the-biden-administration

     

     

  50. 50.

    Felanius Kootea

    January 11, 2022 at 4:00 pm

    @HinTN: Probably depends on the particular at-home test.  My sister-in-law took one that picked omicron up just fine (later confirmed by a PCR test).

  51. 51.

    Mel

    January 11, 2022 at 4:01 pm

    @narya: A challenge that a lot of my neighbors face is accessing the time, transportation, and childcare help necessary to get to community health centers and then wait in line or in a Covid-patient crowded waiting room or outside in inclement weather for a lengthy period of time to try to get the at home tests. Some have waited a couple of hours or more, only to have center staff then announce that they have run out of take home tests. (The health center personnel are doing their best, trying to juggle immense patient loads, staff shortages, and limited numbers of available tests.)

    If the person trying to access the at- home tests has young children at home, or is a caregiver, or is working several jobs / long or unpredictable hours, or relies on public transportation, this can create an insurmountable set of barriers.

    Where I live, the health centers tried to make this less of a burden by also sending a portion of their available tests to county libraries which have drive-up windows, in an attempt to get wider distribution and to avoid at-risk people having to wait in crowded waiting rooms with sick patients in order to pick up tests.

    It was a great idea, but what happened is that most of the library branches with drive up windows are in suburban areas, and most of the tests got snapped up within an hour or so of branches opening, by people who have the schedule flexibility and transportation to get to the branches early / easily by car and wait in line.

    It was a great idea in theory, but was as problematic in practice as delivering free tests just through the already overwhelmed and understaffed health department clinics.

    I don’t think that there is a perfect answer, but it seems like having an online sign up and a registration call center for people to sign up and just have the tests delivered to their homes free of charge, through the postal service and thus without risking exposure or requiring transportation and free time, is  the best bet going forward.

    It bypasses a lot of the hurdles that in-person pickup or labyrinthine insurance reimbursement requirements add to the situation. It also would help to protect vulnerable and low mobility residents.

    It’s not a perfect solution (slow mail, too few carriers, requirement for big initial outlay of personnel and planning to get things rolling and make sure that more than enough tests are being manufactured and made available, homeless persons and those staying with family or friends having a hard time getting access), but currently seems like the best way to reach the greatest number of people with the least burden and risk, and without the uninsured falling through the cracks yet again.

    Supplementing postal delivery with community distribution through homeless shelters, women’s shelters, and health clinics / outreach org could help close at least some of those access gaps.

  52. 52.

    Mel

    January 11, 2022 at 4:08 pm

    @Tazj: Good news.

    I wonder how they will manage the need to get enough /an accurate amount of tests to each household?

  53. 53.

    RaflW

    January 11, 2022 at 8:03 pm

    @Yarrow: & @HinTN:
    Yep. What I’ve read is that the better way to home test is to first swab the throat (back where the uvula is, try not to gag) and then the nostrils. It isn’t in the instructions, and is mostly coming off of UK recommendations, but it seems like a reasonable idea.
    Robert Wachter, MD, UCSF Chair of the Department of Medicine also endorsed this throat-nose method in a recent very popular tweet thread.

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