Medicare Plans Out-of-Pocket Waivers and Deductibles for COVID-19

checkmark Fact checked Contributing expert: Kelly Blackwell - Published: March 12, 2021

 

The COVID-19 pandemic is a declared public health emergency. As a public health emergency, Medicare health insurance providers have waived some out-of-pocket costs such as deductibles, copays, and coinsurance to ensure that Americans have access to prevention, testing, and treatment related to COVID-19 infection.

What you should know:

  • 1 The COVID-19 pandemic has been declared a public health emergency. Medicare health insurers are waiving some out-of-pocket costs to ensure that you have affordable access to prevention, testing, and treatment of COVID-19.
  • 2 Medically appropriate testing for COVID-19 is provided at no cost to you, as are doctor’s visits related to the testing. Approved COVID-19 vaccinations are provided at no cost.
  • 3 As a Medicare beneficiary receiving services from a Medicare approved provider, you’re eligible for some waived out-of-pocket costs, depending on your insurance plan.
  • 4 Cost-saving waivers remain in effect during the state of emergency. Medicare Advantage plans can extend or expand their waivers at their discretion. Check with your plan to see what out-of-pocket waivers are available to you and when they expire.

What does Medicare cover for COVID-19?

Most COVID-19 services are available to Medicaid beneficiaries at reduced or no cost. COVID-19 tests and vaccinations are offered at no cost for Medicare beneficiaries. Telehealth services have been expanded to include virtual or telephone visits with doctors, specialists, and mental and behavioral health professionals at reduced or no cost. Some previous requirements related to prior authorizations and transfers to skilled nursing facilities have been waived.

For example, the Centers for Medicare and Medicaid Services (CMS) is waiving the requirement that a person have a qualifying three-day stay in the hospital before transfer to a skilled nursing facility.  Some Medicare Advantage plans are allowing for free home delivery of prescriptions, and for services to be provided by out of network providers at the in-network cost.

Most Medicare Advantage plans are removing cost barriers to care during all or part of the time the emergency declaration is in place:

  • Aetna and UnitedHealthcare will provide no-cost COVID-19 vaccinations through 2021.
  • Humana is waiving out-of-pocket treatment and telehealth costs for Medicare Advantage plan members through 2021.
  • Cigna is waiving pre-admit and pre-surgical test costs until April 20, 2021, and will allow for direct transfer to skilled nursing facilities until March 31, 2021.

Each insurance company can extend their cost-sharing waivers beyond the end of the emergency declaration. Check with your plan to find out which waivers apply to you and when they expire.

What are the potential savings with waived Medicare out-of-pocket costs for COVID-19?

Potential savings with waived Medicare out-of-pocket costs for COVID-19 are significant, especially if you require more critical care.

The most significant potential savings with waived Medicare out-of-pocket costs for COVID-19 are copays and deductibles for inpatient hospital stays for treatment or complications.  Most Medicare Advantage Plans have a daily copay ranging from $250 to $300 depending on your plan for the first part of an inpatient stay. If that cost is waived, your savings could be as much as $1,500 if you are hospitalized, plus any copays for doctors who see you while you are inpatient, plus your plan’s deductible.

COVID-19 tests and doctor’s visits associated with testing are provided at no cost under Medicare. Depending on what type of test you get and where you get it, your out-of-pocket cost could range from $36 to $180 per test, and possibly more, if you have not met your deductible. If your plan includes a copay or a deductible for lab tests and doctor’s visits, you could save the cost of the test and the copay for seeing your doctor. You may need multiple tests over the course of the pandemic, so as long as COVID-19 testing is provided at no cost, your savings will multiply as well.

Vaccine costs plus administration costs are waived. Depending on the type of vaccine you get, costs for a single injection range from $10 to $26. Some providers charge a fee to administer the vaccine, so you would save on those costs as well.

You may save $203 on your Part B deductible if you are receiving benefits related to COVID-19. With Medicare Advantage Plans, you typically have a higher copay for specialists versus a lower copay for a primary care physician, and higher copay if your provider is out of network. Some Medicare Advantage Plans are waiving these higher copays, so your savings could be up to $40 per specialist visit, and more if your provider is out of network. These visits could be in person or via telehealth.

If you need medications related to treating a COVID-19 infection, and you can only get them from an out of network pharmacy, you only pay the in-network cost. You also save on home delivery of prescriptions with some plans.

How do you know if you qualify for waived COVID-19 costs under Medicare?

All of these waived costs are subject to the service being deemed medically appropriate and must be ordered by a health provider. For instance, if you decide to travel and need proof of a negative COVID-19 test to return home, you may not qualify for waived costs. You must be a Medicare beneficiary to be eligible for waived costs, and you must receive services from a Medicare-approved provider.

All Medicare health insurance providers must provide no-cost testing and vaccines while the emergency is in effect. Your private insurance company has some discretion about which waivers to offer. Check with your plan and your providers to see if you qualify for waived costs.

When do Medicare COVID-19 waivers end?

In general, the waivers may remain in effect for as long as there’s a PHE declaration and Presidential declaration under either the National Emergencies Act (NEA) or the Stafford Act. Telehealth coverage waivers remain in effect until the end of the PHE and amendments made to the Coronavirus Preparedness and Response Supplemental Appropriations Act.

CMS has indicated it will cover the full cost of the vaccine for all Medicare beneficiaries, including those in a Medicare Advantage plan, through 2021. Each Medicare insurer can elect to extend or expand other waivers, and this may vary by state. It’s a good idea to check with your plan to see what waivers are in place and when they will expire, especially if the PHE is extended beyond April 20, 2021. 

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Contributing Expert:

Kelly Blackwell, Certified Senior Advisor (CSA)

Kelly Blackwell is a Certified Senior Advisor (CSA)®. She has been a healthcare professional for over 30 years, with experience working as a bedside nurse and as a Clinical Manager. She has a passion for educating, assisting and advising seniors throughout the healthcare process.