As more Americans test positive for the coronavirus and practice social distancing by keeping six feet away from one another, concerns about what their insurance companies cover continue to rise.
Governors and mayors in New York, San Francisco and Houston have restricted movement, shutting down restaurants and bars to only delivery and take-out orders in an effort to stem the spread of COVID-19 that still lacks a vaccine or cure.
“There is no immunization or antiviral treatment for COVID-19,” said Allison Hoffman, a law professor at Penn Law School in Philadelphia. “If there were immunization, it would almost certainly be covered by all health plans with no cost sharing, as required by the Affordable Care Act known as the ACA.”
While testing remains free in most cases, including people with individual and family coverage and people enrolled in Medicare, many people do not have access to tests in the U.S., potentially delaying treatment.
“Some consumers are concerned their health insurance plan might not cover coronavirus,” said
Scott Flanders, CEO of eHealth (EHTH), a private health insurance exchange in Santa Clara, California that has helped enroll over 5 million Americans. “We tell them not to worry because the coronavirus is covered in much the same way as any other illness.”
A Bankrate.com report demonstrates that nearly one in three U.S. families decided not to seek medical care, including doctor visits to medications, vaccinations and annual exams during the past year because of the costs they would incur.
Almost three in 10 people with health care costs in the past year had to resort to more desperate means to deal with the costs such as taking on substantial debt, borrowing money from friends or family or tapping into retirement savings.
“Health care costs, including the most significant stemming from an unexpected accident or illness, can inflict lasting financial damage,” said Bankrate.com senior economic analyst Mark Hamrick. “One way to guard against this is to save for emergencies. Health care costs are causing injury to Americans’ personal finances, which is why they’re elevating the issue as an urgent political priority.”
Watch Your Deductible
The coronavirus is covered by health insurance providers similar to other illnesses, but that means consumers will still be responsible for their deductibles that are often thousands of dollars.
“If you’re hospitalized or receive medical care for coronavirus, that will also be covered according to the rules of your plan,” Flanders said. “Your deductible may come into play, but rules will vary from one insurer to another. This is a fluid situation, however, and we’re continuing to monitor developments from government regulators and the insurance companies we represent.”
When consumers receive medical care for coronavirus, they are likely to face out-of-pocket costs in the form of a co-pay, deductible or coinsurance before coverage kicks in, but there are no specific restrictions or limitations for coverage of coronavirus.
Americans pay higher rates of cost-sharing than people in almost any other country, Hoffman said. Consumers who have a health plan with a $2,000 deductible would pay for the first $2,000 in medical care before the health plan starts to pay for the care.
The same applies if you have a 10% copayment after that deductible. Patients would pay for 10% of any additional care up to the annual limit of the plan.
Patients who end up getting care in a facility or by a doctor who is out of network for your plan or are transported by an out-of-network ambulance to a hospital, you could be stuck with a large surprise bill.
“This happens more often than one might think and the magnitude of an out-of-network bill for COVID-19 care could be staggering,” she said. “Some states have started to pass laws prohibiting it, since Congress has failed to do so. I do think that there will be public pressure for insurers, hospitals and doctors to meet the need of Americans in this unusual moment without leaving them with unaffordable medical bills. Yet, it is a moment where the gaping holes in our health care financing system become glaringly obvious.”
Blue Cross Blue Shield, one of the largest U.S. health insurance providers, will cover “with no cost share to the member, the appropriate medically necessary diagnostic testing for COVID-19, where it is not covered as part of the Public Health Service response,” said Vincent Nelson, M.D. and vice president of medical affairs and interim chief medical officer at Blue Cross Blue Shield Association in Chicago.
There are 36 independent and locally operated Blue Cross Blue Shield companies that provide health insurance coverage to one in three Americans across all 50 states, the District of Columbia and Puerto Rico.
Any medical care and treatment needed once diagnosis of COVID-19 has occurred will be covered “consistent with the standard provisions of the member’s health benefits, he said. Blue Cross Blue Shield said it will waive prior authorization for medically necessary services and diagnostics related to COVID-19.
Health insurance plans are increasingly covering telemedicine and some doctors have begun to offer non-urgent care by telemedicine, Hoffman said.
Hospitalization and Quarantine Coverage
Patients who are hospitalized or quarantined in a medical facility would receive the same coverage similar to other inpatient stays in a medical facility, Flanders said.
“Specific out-of-pocket costs may apply, depending on the rules of your plan,” he said. “But medically necessary care is covered by all major medical health insurance plans, including inpatient hospital stays.”
Health costs such as doctor visits, hospitalization, laboratory testing and support therapy for the symptoms of the infection typically are covered under health insurance plans and many of these services are already considered to be essential health benefits under the Affordable Care Act, said Michael Levinson, a healthcare attorney and partner with Berger Singerman, a Boca Raton, Florida-based law firm.
“These services must be covered by ACA-compliant individual and small group plans,” he said. “It is important to note that there are many individuals who are covered by short term or limited service plans or health care sharing ministries, and whether or not these people would be covered depends on the limits of their individual plans.”
If you are mandated to self-quarantine at home, your health insurance plan will not pay you to stay at home or compensate you for lost income when you’re away from work, Flanders said.
“Some self-quarantine patients leave home to visit medical providers for tests or check-ups, however, and these would be covered according to the standard rules of your plan,” Flanders said. “Medical care rendered in your own home by a licensed professional may also be covered.”
Consumers who want to undergo non-standard care for treatment or prevention of coronavirus will have to pay for the additional costs themselves.