- Most health plans no longer have to cover the cost of COVID-19 testing, now that the public health emergency has ended.
- All non-grandfathered health plans are required to cover COVID-19 vaccines with no cost-sharing (this continues indefinitely).
- COVID testing and vaccines for people without health insurance.
- Coverage of the costs of treatment will vary according to the type of health coverage a patient has.
Will my health insurance cover the costs of coronavirus testing and treatment?
In general, comprehensive major medical health plans will cover COVID treatment and lab-based testing, albeit with the plan’s regular cost-sharing (deductible, copays, coinsurance).
During the COVID public health emergency, most plans were required to cover the full cost of testing, including lab-based and at-home testing. But that’s no longer the case. So coverage of at-home COVID tests is now optional for health plans other than Medicaid.
How will my health plan cover a COVID-19 vaccine?
The CARES Act (H.R.748, enacted in March 2020) requires all non-grandfathered health plans, including private insurance, Medicare, and Medicaid, to cover COVID-19 vaccines without any cost-sharing for the member (plans that aren’t regulated by the ACA — such as short-term health plans or fixed-indemnity plans — are not included in the vaccine coverage requirement).
This requirement did not end with the public health emergency, so ongoing full coverage of recommended COVID vaccines is the same as the coverage rules for other vaccines recommended by the CDC.
How can the uninsured get COVID-19 testing and vaccines?
How much of COVID treatment costs will health plans cover?
This depends on the details of the specific plan. Although comprehensive major medical plans will generally cover all medically necessary inpatient and outpatient care that someone receives for COVID (or long COVID), “cover” doesn’t mean they’ll pay for all of it.
This is where patients’ cost-sharing comes into play. Under the ACA, all non-grandfathered, non-grandmothered health plans must have in-network out-of-pocket maximums that don’t exceed $9,100 for a single individual in 2023, or $9,450 in 2024 (this limit doesn’t apply to plans that aren’t regulated by the ACA, such as short-term health plans).
So for most patients who need COVID treatment in 2023 and who have comprehensive major medical coverage, out-of-pocket costs won’t exceed $9,100 as long as they stay in-network. But that’s still a huge amount of money, and most people don’t have it sitting around. The majority of health plans have out-of-pocket limits well below that amount, but most people are still going to be on the hook for a four-figure bill if they end up needing to be hospitalized for COVID-19. Although employer-sponsored plans tend to be more generous than the plans people buy in the individual market, the average employer-sponsored plan still had an out-of-pocket maximum of $4,355 for a single employee in 2022.
If you have a health savings account (HSA), you can use the tax-free money in your account to pay for COVID treatment costs. And if your employer offers a flexible spending account (FSA) and you’ve opted to contribute to it, that can also be used for out-of-pocket COVID treatment expenses.
How do I make sure I have coverage to protect myself from COVID?
So what can you do to protect yourself as much as possible in terms of your health insurance coverage? Here are a few pointers:
- If you’re uninsured (which includes having a health plan that’s not minimum essential coverage), you can enroll in a plan through the health insurance marketplace (exchange) in your state during open enrollment, which runs from November 1 to January 15 in most states. You can also enroll if you have a qualifying life event. (Note that some special enrollment periods are ongoing or much longer than normal, including the low-income special enrollment period, Native American special enrollment period, and the loss-of-Medicaid special enrollment period in many states.)
- Enrolling in coverage through the exchange is an excellent opportunity to take advantage of the enhanced premium subsidies created by the American Rescue Plan/Inflation Reduction Act.
- If your income is low (even temporarily, due to a layoff), check to see if you might be eligible for Medicaid.
- If you have health insurance, make sure you understand what your plan covers and what your cost-sharing responsibilities are for various outpatient and inpatient care.
- Check to see how your health plan handles prior authorizations.
- Pay attention to the details of your health plan’s provider network. Your best chance of avoiding balance billing is to make sure you see in-network providers, and you don’t want to be having to sort that out while you or a family member is very unwell.
- Check with your plan to see how telehealth is covered, and be sure you understand how to use the telehealth services.
- If you have an HSA-qualified health plan, try to make contributions to your HSA. Whatever money you contribute to your HSA will be available to withdraw tax-free if you end up needing it to pay out-of-pocket costs for medical care.
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.