How is treatment for long COVID covered by health insurance?

Since early 2020, more than three-quarters of the American population has been infected with the COVID-19 virus – with more than 1.1 million deaths attributed to the disease. And while the vast majority of those infected have survived, the nation is now confronted with the specter of long COVID, a debilitating array of symptoms faced by millions of those survivors.

The millions of Americans facing the prospect of long COVID symptoms are also facing the specter of medical expenses associated with the treatment of long COVID. If you’re wondering whether health insurance will cover those expenses, you’re not alone. Here’s what you need to know:

ACA-compliant individual/family plans

Plans purchased in the Affordable Care Act (ACA) health insurance marketplace (and ACA-compliant major medical coverage purchased directly from an insurer) will cover the ACA’s ten essential health benefits.

Specific provisions, such as out-of-pocket costs, prior authorization requirements, and provider networks will vary from one plan to another. But these plans will all cover the general categories of care that you might need, including inpatient and outpatient care, mental health care, rehabilitation services, and prescription drugs.

Depending on the plan you select, your in-network out-of-pocket costs could be as high as $9,100 in 2023, and as high as $9,450 in 2024. And it’s common for individual/family health plans to only cover in-network care, which means you’ll need to be sure that the providers you want to use are in-network with the health plan you select.

Medicaid

Medicaid is also required to cover the ACA’s essential health benefits. There is variation from state to state in terms of the specific benefits that Medicaid provides, but in general, the coverage is robust and the out-of-pocket costs will be quite low.

Short-term health insurance

If you enroll in a short-term health plan, you could run into coverage problems if you have long COVID. Short-term health plans are not regulated by the ACA, so they don’t have to cover essential health benefits, are not guaranteed issue, and generally have blanket exclusions for all pre-existing conditions.

So, if you already have long COVID – or if you’ve had COVID and could thus develop long COVID in the coming months – a short-term plan is unlikely to cover the costs associated with long COVID. And short-term plans often exclude services that long COVID patients need, such as prescription drugs and mental health care.

Medicare

If you have Medicare, your coverage for long COVID treatment is likely quite comprehensive, although your out-of-pocket costs and access to medical providers will vary depending on how you choose to access Medicare benefits.

Nearly half of all Medicare beneficiaries have private Medicare Advantage plans, with specific benefits, provider networks, and costs that vary by plan. Advantage plans must meet various federal minimum requirements, including covering all of the services that are covered under Medicare Part A and Part B, and having an annual in-network out-of-pocket limit – not counting prescription costs – of no more than $8,300 in 2023 (this upper limit is increasing to $8,850 in 2024, although many plans will continue to have out-of-pocket caps well below the allowable maximum).

For the more than half of beneficiaries who have Original Medicare, coverage is robust but out-of-pocket costs depend on whether they enroll in a Medigap plan (and which Medigap plan they select) or have supplemental coverage from an employer or former employer.

As a general rule, Medicare will cover pre-existing conditions, and costs are not higher for people with medical conditions. However, Medigap plans can impose a pre-existing condition waiting period of up to six months if the enrollee didn’t have creditable coverage prior to enrolling in Medigap.

Employer-sponsored health coverage

If you have an employer-sponsored plan, your coverage is likely quite robust. Small-group plans with effective dates of 2014 or later are required to cover the ACA’s essential health benefits. The ACA’s rules for large-group plans are a little different, but large-group plans tend to be comprehensive.

Regardless of whether you have a small-group plan or a large-group plan, your in-network out-of-pocket costs for covered services can’t exceed $9,100 in 2023 (note that this does not apply to grandfathered or grandmothered health plans). This upper cap will increase to $9,450 in 2024.

One issue with employer-sponsored coverage is that you need to keep your job in order to maintain your coverage. If you’re too sick to work, that could become a problem. Fortunately, there are provisions in place to protect workers’ continued access to health benefits in this situation.

Depending on your circumstances, you might qualify for disability benefits or FMLA (Family and Medical Leave Act) leave. Employers are required to allow you to continue your group health plan during FMLA leave, and have the option to do so during disability leave. (If you don’t have an income during the FMLA leave – from vacation/sick time or disability benefits – you’ll need to make arrangements with your employer to pay your regular portion of the premium, since there won’t be a paycheck from which it can be payroll deducted.)

And if you lose access to your employer-sponsored health plan, you may be able to continue your coverage temporarily with COBRA or state continuation coverage (“mini-COBRA” for smaller employers). Here’s what you need to know about maintaining your coverage or obtaining new coverage if you lose your employer-sponsored plan.

Fortunately, as a result of HIPAA and the ACA, most health plans in the U.S. cannot exclude pre-existing conditions. So the fact that you have long COVID will not affect your ability to get coverage or the benefits that the plan offers in most cases. And if you obtain coverage, your medical needs will be covered at least in part from the first day your plan takes effect, without any sort of pre-existing condition waiting periods.

Under the ACA, individual and small-group health plans with effective dates of 2014 or later are required to cover ten essential health benefits. (Large-group health plans are not required to cover the essential health benefits under the ACA, but that’s because most of them already did, long before the ACA was enacted. The average actuarial value of an employer-sponsored health plan in 2011 was almost 89%, which is roughly equivalent to platinum-level plans under the ACA.)

The essential health benefits encompass a wide range of services that might be necessary for a person with long COVID, including inpatient and outpatient care, mental health care, lab work, pharmaceuticals, and rehabilitation services.

Health plans that are not subject to the ACA’s regulations (such as short-term plans, health care sharing ministries, travel insurance, fixed indemnity plans, etc.) do not have to cover pre-existing conditions, may reject an applicant due to medical history, and do not have to cover the ACA’s essential health benefits. So if you’re dealing with or concerned about long COVID, you’ll want to be clear about whether the coverage you have is a true major medical plan, sold either in the individual/family market or offered by an employer.

If you’re dealing with long COVID, you’ll definitely want to avoid non-ACA-compliant plans if you’re trying to minimize your costs. Those plans, including short-term health insurance, generally will not cover anything related to a pre-existing medical condition.

But it’s also important to understand that you can only enroll in ACA-compliant plans during open enrollment or a special enrollment period triggered by a qualifying life event. This is true for employer-sponsored plans as well as individual/family plans.

Open enrollment for individual/family health plans (purchased through the marketplace or directly from insurance companies) runs from November 1 to January 15 in most states. Individual and family plans purchased between Nov. 1 and Dec. 15 will have Jan. 1 effective dates. Those purchased between Dec. 15 and Jan. 15 will generally be in force on Feb. 1, although this varies a bit in some states. Employers can set their own open enrollment periods, and although it’s common for them to be in the fall, they can occur at any time of the year. You will want to confirm the effective date of your new coverage.

Will certain types of health plans provide better coverage of long COVID expenses?

If you’re dealing with long COVID, you’ll want to carefully consider the plan options that are available to you, either from your employer or in the marketplace/exchange. Your employer may only offer one plan, or they may allow you to select from two or more options. But if you’re buying your own coverage, you might have dozens or even hundreds of plans from which to choose.

The individual market is predominantly HMOs (health maintenance organizations) and EPOs (exclusive provider organizations), and there may or may not be PPO options available. But today’s health plans don’t always match the “rules” that you may have heard about managed care. For example, some modern HMOs allow you to self-refer to a specialist, without having to visit your primary care doctor for a referral. You’ll want to pay attention to details like this if you’re anticipating a lot of medical care.

If PPOs are available to you, they might be enticing because you feel like you can “see any doctor.” However, not all doctors are going to be in-network with a PPO plan. The No Surprises Act protects against “surprise” balance billing. But it doesn’t protect against balance billing if you choose to see an out-of-network provider. You might find that the out-of-network costs with a PPO are quite significant if you go that route, due to substantial out-of-network deductibles and coinsurance, as well as the balance billing.

Tips for choosing coverage

A better approach, in general, is to carefully consider the provider network that each plan offers, and pick the plan that includes your preferred doctors and medical facilities in its network. If you are dealing with long COVID, it may make sense to pick a plan with a fairly large provider network. That is particularly true if you aren’t sure what sort of specialty care you might need going forward. A large provider network will give you access to more medical providers.

You’ll also want to pay close attention to out-of-pocket costs, including the deductible, copays, coinsurance, and the maximum out-of-pocket cap that the plan has. All of the available individual/family plans are going to cover the essential health benefits, but some will have higher out-of-pocket costs than others.

Don’t confuse the out-of-pocket maximum with the deductible, which is the amount you would have to pay for covered services and drugs before the insurance plan starts to pay. Some plans have relatively low deductibles but high out-of-pocket maximums. If you know you’re going to need a lot of care, you don’t want to inadvertently end up on a plan with higher total out-of-pocket costs than you were expecting.

Higher out-of-pocket costs often mean lower premiums, but there’s a lot of premium variation from one insurer to another, even among plans with similar out-of-pocket costs. Here’s a list of tips for choosing the best health plan to fit your needs.

You can compare plan options online or via your state marketplace/exchange. You can also work with a local broker to get help deciding which plans offer the largest choice of in-network options.

Which prescription drugs that treat long COVID will be covered by my insurance?

Each health plan has its own formulary (covered drug list). And although there are basic minimum requirements in terms of what a health plan must include in its formulary, there’s a lot of leeway for insurers to design their pharmacy benefits.

In the individual and small-group markets, formularies must include at least one drug in every United States Pharmacopeia (USP) category and class, or the same number of drugs in each USP category and class as the state’s benchmark plan. Given how many drugs are in some categories and classes, it’s easy to see how covered drug lists can be very different from one health plan to another.

And be aware that for some expensive medications, a health plan may require step therapy before approving coverage. This would mean trying one or more lower-cost medications before switching to the more expensive drug.

Even if two health plans both include a certain drug on their formularies, you could find that the amount you owe at the pharmacy will be very different from one plan to the other. So in addition to determining which health plans have your drugs on their formulary, you’ll also want to see which tier the drug is in, and what that means in terms of how much you’ll pay when you fill the prescription.

Some plans (such as HSA-qualified high-deductible health plans) will require you to pay the full cost of your drugs – at the plan’s network negotiated rate – until you’ve met your overall deductible. Other plans will have copays or coinsurance for each prescription, and may also impose a separate prescription drug deductible that has to be met before you switch to the copay/coinsurance structure. So the actual cost of your medications can vary considerably from one plan to another, even if all of the plans include your medications in their formulary.

If your doctor says you need a certain drug that isn’t on your major medical plan’s formulary and can’t be swapped with one that is on the formulary, there’s an exception request process that you and your doctor can use (this applies to individual/family and small-group health plans). There’s no guarantee that your health plan will make an exception and cover the drug. But there is a protocol in place that ensures an independent external review if the ACA-compliant health plan denies the formulary exception request.

More long COVID resources

Learn more about post-COVID conditions.

Find resources if you have long COVID.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.