March 31st, 2020 BY Jennifer Davis
As America grapples with a viral pandemic, the stress of social distancing and a floundering economy, millions of people have something else to worry about: Does health insurance cover coronavirus testing?
And if you have COVID-19, will your insurance pay for treatment?
These are valid questions. The world has been through pandemics before, but it’s been over a century since the last global epidemic claimed millions of American lives.
In 1918, health insurance didn’t factor into treatments for the so-called Spanish flu. You lived or you died. A grim but black-and-white fact that didn’t depend on health coverage — because there wasn’t any. What we think of as health insurance didn’t exist until about the late 1920s.
The world looks different today, of course.
Health insurance exists, for one thing, as do standards in medical care and treatments. We may have never seen this novel coronavirus before, but medical researchers jumped into action to explore options for treatment and create a vaccine against it. And they’re still working on it.
In the meantime, that handy health insurance plan you bought last fall should cover your testing and hospital care, right?
Well, that depends.
Until recently, that question had no answer.
Few people could have predicted an illness would ravage the country and the world in a matter of three months. That left health insurers — among others — scrambling to find answers to the growing number of questions COVID-19 raises.
All that to ask — are you covered?
Here’s what you need to know about healthcare coverage for coronavirus testing and treatment.
Major Medical vs. Short Term Health Insurance
Whether you have coverage for COVID-19 testing and treatment depends on your policy type: major medical or something else, like short term health insurance.
Major medical insurance might also be called “traditional” health insurance, ACA-compliant plans or Obamacare coverage. It’s the kind of policy you think of when you think about health insurance. Major medical plans:
- Cover 10 essential health benefits
- Guarantee coverage for people with pre-existing medical conditions
- Provide certain consumer protections, like the fact that an insurance company can’t drop you from your plan because you get sick
In short, major medical plans meet all the requirements of the Affordable Care Act (ACA or “Obamacare”). These plans cost more because they cover more. They also come with restrictions on when you can buy one.
Each fall, the open enrollment period allows people to buy a major medical policy on the private market. The open enrollment period runs from November 1 through December 15 in most of the country.
(If you have coverage through work or a government program, your enrollment period differs.)
By contrast, short term health insurance does not cover the same benefits as major medical policies. These plans are designed for a specific purpose: to provide “just in case” insurance for people during times of transition. Short term health plans make sense for some people, such as:
- Young adults who can’t enroll in a family plan
- People who are between jobs
- New employees who don’t qualify for a company health plan yet
Short term policies cover major events, like unexpected illnesses and injuries. They don’t cover essential health benefits (e.g. preventive care, mental health care or prescription drugs, among others). And because they don’t have to adhere to Affordable Care Act rules, they don’t have to accept people with health problems or pre-existing conditions. The tradeoff for limited benefits is lower cost. Short term health plans cost much less than major medical coverage.
COVID-19 Testing as an Essential Benefit
If you have major medical insurance, then testing for coronavirus is covered without any cost sharing — it’s free, in other words.
Congress recently passed a bill that guarantees free testing for COVID-19 regardless of your individual plan. As long as that plan is a major medical policy, it will cover coronavirus testing at no charge. Medicare Part B covers free coronavirus testing as well, as does Medicaid.
(In this context, “testing” refers to the COVID-19 test itself as well as the doctor’s office or ER visit you make to get the test. It does not include any other tests you might get from your provider at the same time, like a test to rule out seasonal flu.)
Short term health plans don’t have to adhere to the same rules as major medical policies. If you have one of these plans, you may have to pay out of pocket for a test and treatment. The same goes for other non-compliant health plans, like healthcare sharing ministries and Farm Bureau plans in states that have them.
But, as Kaiser Family Foundation notes, people enrolled in health plans that don’t meet Affordable Care Act standards count as “uninsured” under the new bill that Congress passed. Because of this, states can open up funds from Medicaid to allow uninsured people to get free coronavirus testing. It’s not a requirement, though.
Testing is covered for free under many plans, but treatment may not be.
Many private insurance companies have stated that they will cover coronavirus testing and treatment without any cost sharing, but there’s no rule in place saying they have to.
Your health plan may cover treatment for complications of COVID-19 the same way it would for any other medical condition that lands you in the hospital. In other words, you would need to meet your deductible and pay your portion of the costs for medical services.
But keep in mind that about 80% of COVID-19 cases are mild, meaning they don’t require any extra care other than rest and time. Chances are that you wouldn’t need hospitalization or more severe treatment methods if you’re in a lower risk group.
For people with medical problems and older adults, though, coronavirus can be deadly. That’s where costly treatment could come into play.
And by the way, there is no cure or treatment for the virus itself at this point. When we say “treatment,” we mean the measures providers take to address severe symptoms and complications of COVID-19.
- If you have a major medical plan that you bought yourself or get from work, testing for COVID-19 should be covered without any cost sharing — i.e., it’s free.
- For people with other kinds of coverage, like short term health insurance, testing for coronavirus may or may not be covered. It depends on the plan and whether your state will allow Medicaid to cover the testing for you.
- Medicare and Medicaid will cover testing for free as well.
- As for treatment costs, coverage varies for private and public health plans. Check with your insurer — or Medicare or Medicaid — for treatment coverage.
How to Get Coverage During a Pandemic
We mentioned above that you can only buy major medical insurance during the open enrollment period in the fall. But there are exceptions to that rule. A special enrollment period allows people going through a major life change to get or change their health insurance. Major life changes are called “qualifying life events” and include things like:
- Marriage or divorce
- Having or adopting a child
- Being released from prison
- Becoming a citizen
There are several ways to qualify for a special enrollment period. Losing your job is another trigger.
Nearly half of people with health insurance get that coverage from work. And with unemployment claims surging to a record 3.3 million last week, plenty of Americans will soon be out of work and out of health insurance because of it.
If you’re among the suddenly unemployed, check to see if you can enroll in a major medical health plan via special enrollment.
Even if you don’t lose your job or qualify for a special enrollment period based on existing guidelines, you may still be able to get major medical insurance.
Some states have their own marketplaces for Obamacare instead of using the federal site at HealthCare.gov. That means they have more leeway in opening up their marketplaces for people to get health insurance.
In response to the coronavirus pandemic, 11 states and the District of Columbia created a special enrollment period for people without health insurance to sign up under Obamacare. If you live in one of the following states or D.C., check to see if you can enroll:
- New York
- Rhode Island
Other options for getting or keeping health insurance during the pandemic include applying for COBRA coverage if it’s available (from your former job) or checking into Medicaid in your state.
Under the Affordable Care Act, most states expanded their Medicaid programs to cover more people at slightly higher income thresholds. If you live in one of these states, see if you qualify. (And even if you don’t, check your state’s Medicaid requirements anyway. You might be eligible.)
What to Do If You Think You Have COVID-19
What happens if you start feeling sick and develop symptoms of COVID-19? Your health insurance should cover testing if you have major medical — and if your area has enough tests to go around. Testing has been an issue from the start in the U.S. If you live in an area with limited tests, you may not get one. And if you do, results may not come quickly.
Still, the best thing to do if you suspect the novel coronavirus is to call your primary care doctor first. If you don’t have a primary care doctor, call your local hospital or emergency room and describe your symptoms.
Avoid physically showing up to a doctor’s office or ER if you suspect COVID-19. You need to call first to contain the spread.
Note: If you have some of the more severe reported symptoms, like shortness of breath, call 911. Not sure if it counts as an emergency? Err on the side of safety and call 911 anyway.
Don’t let the cost of testing and treatment keep you from calling your doctor if you think you have COVID-19.
If you’ve been around someone who tested positive or you develop symptoms, call your provider. Major medical plans cover coronavirus testing for free. Treatment coverage depends on your plan. Getting tested and then isolating at home will help prevent the spread in your community.