Many patients hospitalized for coronavirus treatment won’t have to worry about one headache: If they have health insurance, chances are they won’t be charged out-of-pocket costs for COVID-19 treatment. But that doesn’t mean patients can expect a free trip to the hospital, experts told MarketWatch. Aetna life insurance.
The nation’s largest insurers — including Aetna CVS,
, Blue Cross Blue Shield, Cigna CI,
and UnitedHealthcare UNH,
— are “waiving cost-sharing ” for coronavirus treatment. That means they’re not making patients pay deductibles, copays, coinsurance and other charges if they’re hospitalized with COVID-19, which had killed more than 63,000 Americans as of Friday. (See a full list of what insurers are doing here.)
That’s important news for patients, said Karen Pollitz, a senior fellow at the Kaiser Family Foundation, a nonpartisan nonprofit that researches national health issues. Millions of Americans are losing jobs as the pandemic cripples parts of the economy, and about one in seven say they would avoid seeking treatment for COVID-19 because they don’t think they could afford it, according to one recent survey. Out-of-pocket treatment costs could run to more than $1,300 for a severe case of COVID-19, even for people with health insurance through their job, a recent analysis by the Peterson-Kaiser Family Foundation Health System Tracker found.
So if your health insurer is waiving cost-sharing, does it mean you won’t be charged at all if you’re hospitalized for coronavirus? No.
“There’s always a catch,” Pollitz said. “You still could have out-of-pocket costs even if your insurer says they’re going to waive all the cost-sharing.”
Even though health-insurance companies are waiving cost-sharing for their members, people who get health insurance through their jobs may still end up having to pay for treatment. That’s because employers with “self-funded” or “self-insured” health plans can opt out of waiving cost-sharing for their employees. A self-funded or self-insured health plan means the insurance company administers the plan and the employer pays the claims. So even though your health insurance card may say Aetna on it, your employer could be footing the bill.
Individual medical insurance
Most people who get their health insurance through their job are in a self-funded or self-insured plan, Pollitz said.
If you have health insurance through your job and want to know if your employer is self-funded and whether it’s waiving cost-sharing for coronavirus treatment, call your human-resources department or whoever handles your employer’s health insurance to find out, said Caitlin Donovan, a spokeswoman for the Patient Advocate Foundation, a nonprofit that provides case management and financial aid to patients with chronic, life-threatening conditions.
Aetna, Anthem, Blue Cross Blue Shield, Cigna, Humana and UnitedHealthcare are all allowing employers with self-funded health plans to opt out of waiving cost-sharing. An Aetna spokesman confirmed that self-funded employers can opt out, but did not comment further; Cigna did not respond to a request for comment.
Anthem “is strongly encouraging participation by our self-funded employers and will work with them to ensure their employees’ needs are met. These employers will, however, still have the option to opt out of participation,” the company said in an announcement.
Blue Cross Blue Shield spokesman Taylor Laabs said, “BCBS companies are committed to working with self-funded employer groups, state Medicaid and CHIP agencies to ensure that beneficiaries have access to needed testing and services as well.”
A Humana spokesman confirmed that some members may be part of a self-funded plan that opts out of waiving cost-sharing. “While this will not impact a participating provider’s reimbursement, it means that some members may be responsible for their cost share for COVID-19-related treatment,” said spokesman Mark Mathis. “If members are unsure if they fall into this category, they should confirm their coverage with their employer or contact Humana.” Humana members with questions about COVID-19 coverage can look at FAQs posted here.
Employers with self-funded plans could see their health-care costs go up if they participate in waiving cost-sharing: Claims could increase by as much as 7% this year, the Society for Human Resource Management wrote in a recent blog post, citing an analysis by the risk-management firm Willis Towers Watson. (SHRM, which represents more than 300,000 human-resources professionals, did not respond to a request for further comment.)
Employers with self-funded plans are deciding whether to waive cost-sharing “at a time when many companies are already struggling with the business impact of COVID-19 and facing the prospect of furloughs and layoffs,” wrote Tracy Watts and Beth Umland of the human-resources consulting firm Mercer. “Any decision that is likely to result in additional cost will need to be weighed carefully.”
Aetna, Anthem, Blue Cross Blue Shield, Cigna, and UnitedHealthcare are waiving cost-sharing until either May 31 or June 1. Humana has not set an end date. Insurers are continuing to monitor the situation to decide what steps they may need to take next, a spokeswoman for America’s Health Insurance Plans said. “My expectation is if this is still going strong at the end of May, they’ll face pressure to extend those deadlines,” said Donovan of the National Patient Advocate Foundation.
Even if your insurance company doesn’t make you pay a deductible, copay or coinsurance, there’s still a chance you could get hit with a surprise medical bill after a hospitalization, Pollitz said. In its study of COVID-19 treatment costs, the Peterson-KFF Health System Tracker estimated that 18% of patients hospitalized with severe pneumonia, which can be a complication of COVID-19, could see bills for out-of-network charges. (Out-of-network charges, also called balance bills or surprise bills, are from providers that haven’t negotiated a billing rate with your health insurance plan.)
Coronavirus patients could end up with a surprise bill if they need treatment from specialists such as pulmonologists or infectious-disease doctors who aren’t in their network, according to a blog post for the health-policy journal Health Affairs.
“Whenever you go to the hospital, you don’t just get a bill from the hospital — you get a bill from every doctor who comes into the room, who touches your labs, who anesthetizes you,” Pollitz said. “All of those different professionals can bill you separately, so people may get dozens of bills after a hospitalization.”
Curbing surprise medical bills has been a goal of the Trump administration, and it has continued to be a priority during the pandemic. In March, officials announced that patients wouldn’t get surprise bills for coronavirus testing. The $2 trillion Coronavirus Aid, Relief, and Economic Security (CARES) Act stipulates that hospitals can only accept federal relief if they agree to “abstain from ‘balance billing’ any patient for COVID-related treatment,” according to the Department of Health and Human Services.
But there are some questions about how exactly surprise billing will be prevented. For example, how will patients be notified that they’re not supposed to get surprise bills, and what do they do if they get one? HHS did not respond to a request for comment.
“You should delay before you pay,” Donovan said. “Things are changing so rapidly on a daily basis. Just because you get a bill today doesn’t mean that some legislation might pass that might mean you don’t have to pay that bill.”
If anything strikes you as odd, or if you’re being billed for a treatment you don’t remember receiving, call your provider and ask about that part of your bill. Mistakes are common, and often involve a provider billing a patient directly instead of submitting a claim to an insurance carrier, Donovan said. “Even just typos can add costs to your bill,” she said.
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An “explanation of benefits” can look a lot like a medical bill, but it’s actually a statement that explains what your insurance will be covering and how much you’ll be expected to pay. The amount listed on the EOB should be the same as the one listed on the bill — if it’s not, there’s been a mistake, Donovan said.
Under the CARES Act, hospitals that receive federal relief funding are supposed to sign an agreement pledging not to charge patients surprise bills for coronavirus treatment. It’s worth calling and pointing this out to a hospital billing office if you get a surprise bill, Pollitz said.
If you get a surprise bill that’s out-of-network, call your insurance company and ask for it to be counted as an in-network procedure, Donovan recommended. “I think you have a very strong argument to appeal to your insurer that it should be counted as in-network,” Donovan said. “There are so many extenuating circumstances going on right now.” If a phone call doesn’t work, you can appeal in writing. The Patient Advocate Foundation has an online guide to the process with sample appeal letters.
If your final bill is too big for your budget, sit down and evaluate your finances and see how much you can afford to pay up front. Many hospitals offer financial aid programs that let patients pay off bills gradually. “No hospital expects you to have thousands of dollars on hand — very few people do,” Donovan said. “Letting them know you intend to pay the bill and entering a payment plan might be the least stressful way to handle that situation.”
“Given that there seem to be a lot of providers and insurers who are making the extra effort to be helpful now, if you get an out-of-network bill, it’s worth it to call the billing office,” Pollitz said. “It’s worthwhile trying to ask if they could reconsider, because times are tough now for everybody.”