We’ve been through the process of learning about the coronavirus and its impact on various parts of our lives. And, as COVID-19 continues to spread, many of us will need to seek medical attention. How will health insurance benefits cover testing and treatment for COVID-19? Is the federal government making tests free to everyone? What happens if you need to see a doctor for another condition, should you risk exposure? Will uninsured Americans and those who lose their jobs be able to get insurance?
There are a lot of questions to be answered. In this article, we’ll take a look at health insurance and COVID-19, including the cost of testing, the role of telemedicine, and how different types of insurance may cover treatment. We’ll also discuss special enrollment for Affordable Care Act (ACA) plans and other coverage options for those who are uninsured amid this pandemic.
This information can provide some base knowledge as you navigate the situation. As always, however, consult your health insurance policy or contact your health insurance company with questions about your plan’s specific benefits.
Is COVID-19 Testing Free?
Employer group and private individual plans
Testing is covered. The Families First Coronavirus Response Act, which President Trump signed into law on March 18, 2020, requires group and individual health plans to cover COVID-19 diagnostic testing without cost-sharing (e.g., copay, coinsurance). This includes the cost of a provider, urgent care center and emergency room visits in order to receive testing.
If your visit doesn’t result in a COVID-19 test or you receive other services and care, it may be subject to cost-sharing as detailed in your policy or not covered at all.
Medicare
Medicare covers COVID-19 testing under Part B (medical insurance) as long as the following apply:
- The test is ordered by a doctor or healthcare provider who accepts Medicare.
- You were tested on or after Feb. 4, 2020.
Original Medicare typically covers clinical diagnostic laboratory tests with no cost-sharing, which means your Part B deductible and coinsurance should not apply.
Short-term medical insurance
The Families First Act does not apply to short-term health insurance and other plans that are not subject to the Affordable Care Act. It is common, however, for short-term medical insurance plans to cover benefits for lab testing, as well as telemedicine benefits that could help determine whether or not you need testing. Check with your insurance company to see what diagnostic services your short-term policy covers and how it shares the cost.
Should you experience symptoms of COVID-19, you can use online screening tools such as the CDC’s Coronavirus Self-Checker or follow your state health department’s recommendations to determine next steps. For the most part, health departments advise contacting your healthcare provider for guidance if you are symptomatic but don’t need emergency care.
Will Insurance Cover Telemedicine?
Whether or not you have COVID-19 symptoms, you may want to consider telemedicine if you feel ill and need medical attention at this time. Doing so could help you avoid visiting a clinic or hospital and thereby lessen your chance of exposure to the coronavirus and other illnesses. It could also help save you money. A reason to use telemedicine is that it will typically cost you less than $50 compared with hundreds or even thousands for a trip to the emergency room.
As healthcare providers become overloaded with COVID-19 patients, telemedicine can help triage patients to determine who can self-treat at home and who needs to go in for testing and medical attention. While an actual testing for the coronavirus cannot be administered via telemedicine, healthcare providers can assess your symptoms, make recommendations and monitor your condition this way.
Other conditions such as sinus infections, pink eye, bronchitis and the flu and can also be diagnosed and treated through telehealth visits. Mental health professionals may also offer telemedicine sessions, making it possible for people to continue therapy as more areas ask residents to shelter in place.
Telemedicine benefits are becoming more common among short-term and major medical insurance plans. As part of the federal government’s response to the COVID-19 outbreak, Medicare recently expanded telehealth services including office visits, mental health counseling and preventive care screenings to its beneficiaries on a temporary and emergency basis.
Before you schedule a telemedicine appointment, check with your insurer to see what telemedicine care your plan covers.
Do Health Plans Cover Coronavirus Treatment?
As with testing and telemedicine, coverage for healthcare-related to COVID-19 will vary based upon what kind of insurance you have and your policy details.
Whether you have an individual or group major medical plan, or a short-term medical plan, your out-of-pocket costs for the treatment of COVID-19 will depend on factors such as:
- The specific medical care you receive (e.g., tests, treatment, hospitalization, length of hospital stay).
- Whether you use in- or out-of-network providers.
- What your providers charge for services.
- Your policy’s deductible, copayment and coinsurance.
What about vaccinations? There is not yet a vaccine for the new coronavirus. Companies and academic institutions are working to develop one; however, experimental vaccines must be thoroughly tested for safety and effectiveness before they can be approved, produced and administered. Even with trials now underway, it could be a year to 18 months before a viable vaccine becomes available. How your health plan will cover a CDC-approved vaccine once it hits the market will also depend on what kind of insurance you have.
Employer and Individual Plans
Your job-based health insurance isn’t required by the Families First Coronavirus Response Act to cover treatment for complications related to COVID-19; however, most large-employer plans cover physician and hospital services and are likely to cover testing and treatment according to your policy’s cost-sharing requirements.
The Families First Coronavirus Response Act doesn’t require plans to waive any costs related to treatment. Regardless, under the Affordable Care Act, small group and individual major medical plans must include the 10 essential health benefits. Among them: ambulatory, emergency and laboratory services as well as hospitalization and prescription drugs. That means medical services related to COVID-19 will likely be covered according to your group or individual policy’s cost-sharing and network requirements.
One analysis found that someone with job-based health insurance could pay $1,300 or more out of pocket for treatment if they are hospitalized with a severe case of COVID-19. Estimates were based on the cost of hospitalization for severe pneumonia with complications. In these cases, in-network charges for people with employer insurance averaged $20,000 — insurers covered most of the cost with insured individuals being billed as much as $1,300 or more.
The ACA limits cost-sharing for in-network covered benefits under most private plans to $8,150 for single coverage and $16,300 for family coverage in 2020. This represents the upper threshold of what someone with a group or individual plan might pay out of pocket, depending on the treatment they receive.
Once we do have access to a CDC-approved vaccine for the coronavirus, it’s likely that all health plans subject to the Affordable Care Act will need to cover it at no cost. For example, the ACA currently requires major medical policies include certain vaccinations (e.g., the seasonal flu shot) be provided without cost-sharing — deductible, copay and coinsurance do not apply.
Short-Term Health Insurance Plans
The Families First Coronavirus Response Act does not require short-term medical plans to cover costs related to the treatment of COVID-19. And, while short-term medical plans are exempt from the ACA, they are likely to include coverage for medical services necessary to treat the coronavirus.
The ACA’s cost-sharing limits don’t apply to short-term plans. Your policy will detail cost-sharing requirements (i.e., deductible, coinsurance and copayment), which may help you estimate your potential out-of-pocket responsibility for treatment of COVID-10. Maximum benefits paid for a short-term policy coverage period may be as much as $1 million, depending on your plan.
As for a future vaccine, coverage will vary by plan because short-term health insurance is not subject to ACA requirements.
Medicare
Adults age 65 and older are among those at higher risk of becoming seriously ill if they contract the coronavirus. Most Medicare beneficiaries fall into this demographic. That’s a big reason telemedicine services have temporarily been extended to Medicare beneficiaries — it’s important to mitigate their risk of exposure to COVID-19.
If you are enrolled in traditional Medicare and need treatment due to complications from COVID-19, Medicare will cover a range of inpatient and outpatient services. For hospital admission, your care would be subject to the Part A deductible — $1,408 for 2020. If you were to require an extended stay, a $352 copayment per day for days 61-90 would apply. Outpatient services covered under Part B would be subject to the Part B deductible, which is $198 for 2020, and 20% coinsurance for most services (e.g., physician visits, emergency ambulance transportation.
If you have a Medigap plan or other supplemental coverage, it may cover some or all of your cost-sharing requirements. Cost-sharing requirements vary across Medicare Advantage plans.
Medicare Part B covers some preventive vaccines such as influenza, pneumococcal and Hepatitis B without cost-sharing. If a COVID-19 vaccine becomes available, traditional Medicare and Medicare Advantage plans are required to cover it with no cost-sharing.
Special Enrollment for the Uninsured
Open enrollment for 2020 health insurance plans ended in late 2019 in most states. However, as a result of the COVID-19 outbreak, some states reopened their health insurance exchanges to anyone who needsed to enroll. These special periods lasted through the summer in many areas.
The loss of job-based health insurance is also a qualifying life event, which means you may be eligible for a special enrollment period regardless of where you live. Visit your state-based or federal exchange as soon as possible to start the application process if you have lost your job — special enrollment periods are limited to a certain number of days following your change in circumstances.
ACA subsidies are available during special enrollment. Income-based premium tax credits and cost-sharing reductions are available to those who qualify and enroll through an ACA exchange.
And, if you don’t qualify for a subsidy, don’t meet Medicaid criteria, and feel like an ACA plan is too expensive for you, you may want to consider a short-term health insurance plan to help with the cost of unexpected medical expenses until you find a new job with benefits.
Whatever your health plan, consult your policy or contact your insurance company with specific questions about coverage for COVID-19 (or any other healthcare). Seek medical attention if you show symptoms, and stay healthy and safe.
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