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As we continue to navigate through the effects of COVID-19, many questions arise when it comes to insurance coverage. Does your specific insurance cover testing? Does it cover treatment? How can I find out my coverage options?
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The short answer is it depends on your coverage. Health insurance coverage varies widely, depending on where you live and how you obtain your coverage. Almost half of Americans receive their insurance coverage from their employers. Those plans are managed by both the federal and state guidelines, which depend on the group size and whether or not the plans are self-insured or fully insured. So how does Coronavirus coverage fit into these health plans?
Let’s begin with testing. The Families First Coronavirus Response Act states that Medicare, Medicaid, and private health insurance plans are required to cover the cost of Coronavirus testing, without cost-sharing or pre-authorization requirements. This is including lab service costs and provider fees at doctor’s offices, urgent care clinics, and emergency rooms where tests are given. Because this act is federal law, self-insured and fully-insured plans apply to this rule. However, the testing coverage requirements that are imposed on some states are only applicable to fully-insured plans.
Plans that are not considered minimum essential coverage, for example, short-term health plans, fixed indemnity plans, and healthcare sharing ministry plans are not required to cover COVID-19 testing. Some of these plans do volunteer to cover COVID-19 testing, so look to your plan for specifics.
Some states, like Washington, have extended their testing coverage requirements to include these short-term plans, but most states have not imposed further requirements for these plans.
If you are uninsured, states can use their Medicaid programs to cover COVID-19 testing to cover their uninsured residents. There is $1 billion in federal funding to reimburse providers to cover COVID-19 testing for uninsured patients.
Now, let’s get into treatment coverage. As of right now, there is no specific treatment for COVID-19, most people will not need treatment, but around 20% of patients will be hospitalized, and 20% of those patients will need intensive care. This inpatient care is considered an essential health benefit for all ACA-compliant individual and small group health plans. Large group plans are technically not required to cover essential health benefits, but they are required to provide “substantial” coverage for inpatient care.
Even with coverage, inpatient care is expensive. The ACA states that all non-grandfathered/grandmothered plans must have in-network out-of-pocket maximums that can reach up to $8,150 for a single individual. Most COVID-19 treatment costs will not exceed this amount, but many health plans out-of-pocket limits are below that amount. Which leaves patients that need hospitalization with a four-figure invoice.
Some states, like New Mexico and Massachusetts, have required state-regulated insurers to cover treatment and testing without cost-sharing. Minnesota is encouraging its providers to do the same.
Most states are both encouraging and requiring state-regulated providers to allow testing and treatment as in-network, whether or not the medical providers are in the plan’s network. Patients may still be subject to balance billing because out-of-network providers do not need to accept the payment as payment-in-full.
ways to ensure that you are protected
- If you are uninsured there is a COVID-19 special enrollment period in some states. If your state is included, an ACA-compliant plan is a great option. If you have a low income, you could also be eligible for Medicaid.
- If you currently have health insurance, understand what your plan covers, and how your cost-sharing responsibilities for in-patient and out-patient care may apply.
- Look at your health plan to see how it handles prior authorizations.
- Look at the details of your health plan’s provider network. If you see in-network providers you have a better chance of avoiding balance billing.
- Check to see if telehealth is covered, for less-severe cases, this is the best way to help prevent the spread of COVID-19. Some health plans are eliminating or reducing cost-sharing for telehealth services.
- If you have an HSA-qualified plan, you can devote your pre-tax money to your account for the year. The money you contribute to your plan is able to be withdrawn tax-free for out-of-pocket health care expenses.