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Which COVID test should you take, and how do you get reimbursed?

Jessica Capobianco performs a COVID test on 14-year-old Brady Martel at the Bromfield School in Harvard, Mass. (Jesse Costa/WBUR)
Jessica Capobianco performs a COVID test on 14-year-old Brady Martel at the Bromfield School in Harvard, Mass. (Jesse Costa/WBUR)

Editor's Note: This is an excerpt from a special coronavirus edition of WBUR's morning newsletter, WBUR Today. You can get regular weekday updates about the latest coronavirus surge and other news Boston is talking about by signing up for WBUR Today.


Let's start with some good news: There are clear signs that the latest, most severe spike in COVID-19 cases may have peaked in Massachusetts.

Throughout the pandemic, we’ve talked a lot about leading and lagging indicators when it comes to this virus. Those indicators loosely follow the cycle of illness: There's evidence someone may be sick, they confirm it and, in some terrible cases, they get worse and potentially die.

With COVID, which is being closely tracked, we see that cycle play out with the Massachusetts Water Resource Authority's wastewater data, cases and positivity rate as leading indicators, and hospitalizations and deaths as lagging indicators.

So here's the latest poop data from the MWRA:

As you can see, the wastewater measurements are dropping almost as quickly as they spiked after Thanksgiving. Now, a week or so after this clear turn in results, we're starting to see cases and the seven-day average positive rate begin to drop. There are early indicators that hospitalizations and deaths may have peaked as well, though we need another week or so of data to really evaluate that trend.

Phew, right?

Yes, it's definitely good news. But don't declare victory just yet. You should also remember even now, after more than a week of dropping like Wile E. Coyote off a cliff, there is still more COVID in our wastewater as there was in the peak of last year's surge.

Look at that chart again. The 2020-2021 holiday surge, which once loomed like Everest on this chart, now looks like Winter Hill compared to the 2021-2022 spike. It's no wonder people feel like omicron is out to get everyone.

Let's get into the nitty gritty of testing, a subject that somehow gets more confusing by the day. We'll go over some of the most common questions, and then WBUR health reporter Gabrielle Emanuel will discuss the bewildering world of insurance reimbursements.

Testing FAQ

Now, what should you do to get omicron off your porch? If you're reading this, there's a good chance you're someone who's gotten their vaccine shots, including a booster. And if you haven't, go ahead and get an appointment right now. Experts agree the shots are safe and the best way to protect against severe COVID. What else can you do? The same thing you've been doing: avoid crowds, mask up, wash those hands and take those tests.

And because literally nothing in this pandemic can ever be simple, let's talk about the ins and outs of COVID testing, something that most people thought they understood. But then, at-home tests became a viable (if scarce) option, with confusing guidance and even more confusing reimbursement plans. PCR test sites suddenly started drawing crowds like opening day at Sullivan’s. And the feds started offering to send COVID tests to your door, with some slight hiccups when it came to those living in apartment buildings or multi-family homes. It's been a lot to sort through.

How do they work?

With at-home antigen tests, you swab the inside of your nose to collect a sample on a swab and stick it in the accompanying testing tool, be it a plastic strip or cardboard holder. Then you wait, as the test performs a chemical reaction to try and detect COVID-related antigens in your system. Antigens are signs your body has been fighting a specific infection. If they're there, that means you're fighting COVID, which means you have COVID, which means stay home and isolate.

PCR tests, meanwhile, are much more sensitive. The PCR stands for polymerase chain reaction, a time-honored process where you or a tech collects your sample and sends it to a lab. What happens next is incredibly technical, but the five-cent version is that the sample is heated, spun and treated with material to make billions of copies of any bits of COVID DNA, generating enough for the lab equipment to detect it in your sample.

So process-wise, at-home is Sherlock Holmes, deducing clues from what's left at the scene (antigens), while PCR is more like a Hollywood crime lab, enhancing and enhancing to find the smallest trace.

Which test to take?

In all honesty, pregnancy tests offer a good analogy:

  • If you suspect you're pregnant, go get a home test. If it's positive, go get a test with your doctor.
  • If you have symptoms or suspect you've been exposed to COVID, get an at-home COVID test. Take multiple tests over several days if you can. If you get a positive result, talk to your doctor. She may want you to follow up with a PCR test, or may want you to just stay home and isolate for a minimum of five days.

Which is better?

Each test has its advantages and disadvantages. Basically, they follow the two-out-of-three rule: You can pick two of the following qualities, but not all three: fast, easy, accurate.

  • PCRs are easy and accurate, but they aren't super fast. Results take 1-3 business days to return because they have to be sent to a lab for analysis. Sometimes labs get backed up, and the results can take even longer. The big drawback with PCR tests right now is the outrageously long lines. This has politicos scrambling, but it may take weeks to provide more testing sites. With the current wave ebbing, it's not clear how useful that will be.
  • At-home tests are easy and fast, but the DIY nature of the testing and materials used mean they aren't as accurate as a PCR, especially when you get a negative result. If used correctly, a positive test is almost always reliable — but negative, not so much. And studies have shown the tests are much more accurate with people who are already showing symptoms.
  • Why the difference in accuracy? Remember that the at-home test is looking for specific antigens, which are the result of your body fighting COVID. If you have very little COVID in you — or the infection is just starting — there's a chance the test won't detect any antigens. PCR tests can detect almost any amount of COVID by running your sample through the chemical equivalent of a Xerox machine a couple billion times.

A quick word about following instructions: Researchers increasingly believe omicron may replicate in the throat before the nose. So, there's been some chatter online about people claiming better results with an at-home test by swabbing their throats instead. Don’t do this! No one worth mentioning is advocating you do this with a test designed for nose swabs. The serious people who advocate for this are asking for more research to back up the claims, and for the FDA to provide guidance on procedure, not for you to go rogue and jam a q-tip down your throat.

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OK, maybe you're one of those people who want only the best. You would never settle for a Gobot version when there are Transformers to be had. Why would you ever take an at-home test?

Even with lesser accuracy, you can take multiple rapid tests in the time it would take to get a PCR. And with each test you take, the chance that you miss an infection falls. You have to pay cash up front for the at-home tests, even though you can be reimbursed by your insurance carrier later (more on that below) or get a few to start you off for free from the feds (more on that later, too).

Do they work with omicron?

The short answer is yes.

Slightly less short answer: PCR tests work with the newest variant for sure. And new research shows that at-home tests perform as well with omicron, i.e. they're still less accurate than PCR tests, but no worse than with previous variants. And, like I said above, when it comes to people exhibiting symptoms, at-home test accuracy is nearly on par with PCR tests.

When should I take a test?

Here is the general guidance: Health officials suggest you get tested on days three and five after exposure to someone who has tested positive, or if you feel symptomatic at all. But there are plenty of other instances in which you may need to get tested, too.

  • If your work requires it, take the test as outlined.Same with schools.
  • You may also need to get tested if you plan to travel, though the rules there are almost constantly in flux.
  • Given all the information above, you are fine to start with an at-home antigen test and then advance to a PCR. Speaking with the Boston Herald, infectious disease specialists Dr. David Hamer and Dr. Todd Ellerin laid it out clearly: If you need a test right away, go with an at-home, and, if possible, take multiple tests over the course of a few days to increase the accuracy. These tests are really good at indicating when you may be most infectious. If it's a pooled testing situation (like a school), PCR tests, which are more sensitive, can catch infections early.

What about my kids?

Your kids can take COVID tests. Just this week, Massachusetts said it will make free at-home tests available to schools to help identify cases where kids may be contagious, rather than rely on the previous "test and stay" system, where kids were given rapid tests after potential exposures.

There are videos knocking around to help you explain the PCR test process to your kids, with the emphasis on staying still and letting them know it's OK if it feels a little uncomfortable. Here's one from Boston Children's Hospital, which is short and uses cartoons. Here's another from the Mayo Clinic, which shows a real kid getting a test.

There are videos available for at-home tests, too, like this one from Walgreens with an absurdly adorable little girl getting tested. It's geared toward parents, but honestly if you're a little uncertain about how to manage the at-home test, you should watch this or another instructional video.

OK, I'm ready: Where can I get these tests?

  • Remember those long lines? Those were for PCR tests, and there's been a push to open more sites and expand services during this omicron wave. Click here to see the state's online tool for finding testing sites near you.
  • There's even a bit of a guerilla effort to help folks find tests thanks to Olivia Adams. (Yes, she’s the same woman who developed a vaccine mini-site last year when getting your jab was a tough proposition.) Click here to try it out.
  • But it's not like we're swimming Scrooge McDuck-style in a vault full of at-home tests, either. These have been hard to come by, as people rushed to the pharmacy to snap them up for the holidays. That supply pressure increased when the feds made the purchase reimbursable by your insurance. (More on that below.)
  • On Tuesday afternoon, a new federal website launched to provide up to four at-home tests per household per month. The site address is https://www.covidtests.gov/. The Biden administration said it will also launch a hotline for those who don't have access to internet service, though it's not clear when that number will be available.
  • White House officials say the covidtests.gov tests are coming from new manufacturing capacity. This order should not interfere with existing supplies that your local pharmacy, health clinics and state governments are relying on.
  • And Massachusetts has also made free at-home tests available to local communities, schools and other key stakeholders, who will then dole them out to people.You can also buy these at-home tests, and then apply for a reimbursement from your insurance company to cover the cost. WBUR health reporter Gabrielle Emanuel has answers to our questions about that process below.

And now, a Q&A about at-home test reimbursements

At-home COVID-19 tests. (Photo Illustration by Scott Olson/Getty Images)
At-home COVID-19 tests. (Photo Illustration by Scott Olson/Getty Images)

WBUR health reporter Gabrielle Emanuel has been in the trenches of omicron reporting, and this week she spoke with health insurance companies and policy leaders. She kindly answered some of our questions about getting refunds for COVID-19 tests.

Fill us in on the basics, what’s new this week?

Beginning this past Tuesday, people can request up to four free rapid tests per residential address to be delivered through the mail. Orders are placed at covidtests.gov or through a phone number. The federal government says the tests will ship within seven to 12 days, and priority is being given to communities that are particularly vulnerable and have been disproportionately hit hard by the virus.

In addition, as of this past Saturday, private health insurers are required to cover the cost of eight at-home COVID tests per member per month. In many cases there are two test kits per box, meaning four boxes will be covered.

What’s the system for private health insurers to cover rapid tests?

The federal government is incentivizing insurers to arrange a system where people can get tests with no out-of-pocket costs. If they set up such a system, then, when it comes to reimbursing tests bought elsewhere, insurers can cap the repayment at $12 a test. Otherwise, private insurers must cover the retail price of a test whatever it costs. But, at least initially, many insurers are simply going with a reimbursement model.

One of the challenges is that each insurer is coming up with its own system. So, there is likely to be a fair bit of confusion as people figure out what their insurer is doing and how it may change in the near future. According to Gregory Winter, a spokesperson for Blue Cross Blue Shield of Massachusetts, health insurers were given only five days to create these programs.

Blue Cross Blue Shield of Massachusetts is starting with a reimbursement system, with a submission form available on its website. That form will be replaced on Jan. 23 once the insurer develops a new form. Plus, they are working on creating a national preferred pharmacy network that will eventually allow customers to go to certain pharmacies and obtain authorized tests for $0.

Harvard Pilgrim Health Care Commercial members can visit a Walmart or Rite Aid pharmacy right now and purchase the tests with no upfront cost by showing their insurance card.

Does this do anything to address how hard it is to find rapid tests?

So, the insurance reimbursement system helps address the cost of at-home rapid tests, which has been much higher in the U.S. than in other countries. However, it does not address the challenge of actually finding rapid tests to buy (they’ve been in very short supply) or the delay in shipping tests when they are available online. I found tests online, but they will not ship until mid-February. That’s not helpful for someone who needs a rapid test now.

There is also some concern that with private insurers covering the cost of at-home tests, that might drive up demand even more. However, it remains to be seen how many people will use this program.

Who is footing the bill?

Private insurers. The federal government is not providing money to cover the cost of at-home rapid tests. The administration points to COVID legislation from 2020 that requires insurers to cover COVID testing with no cost-sharing for patients. This requirement will only last the duration of the federal public health emergency.

What about people who don’t have private health insurance?

This policy only applies to people who have private health insurance, which is about 45% of the U.S. population.

Under the American Rescue Plan, Medicaid is already supposed to cover FDA-authorized at-home COVID-19 tests. The administration also has plans to get tens of millions of tests to the uninsured via health clinics and other sites.

Medicare covers more than 60 million seniors — a segment of the population that is at higher risk of developing severe illness due to COVID — but does not cover at-home COVID tests. However, they do cover COVID tests performed in a clinical setting or when ordered by a physician.

For the tens of millions of people who have Medicare Advantage — where coverage is provided through private insurers — policies vary based on the carrier.

“Although not mandated by the federal requirements, we are working with CMS [Centers for Medicare & Medicaid Services] to determine if we can provide coverage for at-home COVID-19 tests for our Medicare members,” said Kathleen Makela, a spokesperson for Tufts Health Plan and Harvard Pilgrim Health Care, which share a parent company.

You tried to get rapid tests. How easy was it?

I used the federal website to get four free rapid tests sent to my home. That was a very simple process for me. I just filled in my address and clicked a button. But it remains to be seen when they will arrive. Also, I’ve seen reports that people living in some multi-unit buildings have had issues, as well as people who live in buildings that are technically commercial buildings. Apparently, they should file a service request with USPS.

I also bought rapid tests online and filed to get them covered by my insurer. The first challenge was finding rapid tests to buy and then I was limited in how many I could purchase. The site I went to limited me to two boxes with two tests each — but my household has four people on private insurance, making us eligible to get 32 tests covered. So, we will need to buy more tests in separate purchases and then fill out one reimbursement form for each family member. It turns out to be a bit cumbersome.

The federal government has been criticized for not detailing how a reimbursement system should be designed. This means an insurer — the company that, as we said, is footing the bill — could make the process onerous and complicated. It’s also worth noting that there is no requirement for how quickly people must be reimbursed.

Homework: OK, it's not homework per se, but if you're both worried about losing your vaccination card and a little technophobic, WBUR fellow Vanessa Ochavillo has written a short and helpful explanation of how to get that little QR code onto your phone.


WBUR's Gabrielle Emanuel contributed to this report.

Related:

Roberto Scalese Twitter Senior Editor, Digital
Roberto Scalese is a senior editor for digital.

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