The recommendations about getting care for coronavirus (COVID-19) are changing rapidly. Check the NY Department of Health’s website on Coronavirus information for the most up-to-date information on what you should do. You can also check the Center for Disease Control’s website for more information.

If you are experiencing symptoms, if possible, you should call ahead to your health care provider or local health department before seeking treatment in person.

NY Coverage. If you have individual or group health insurance coverage that you or your employer bought in New York, including through the NY State of Health Marketplace or the New York State Health Insurance Program (NYSHIP) for public employees, you are covered for the testing and treatment for novel coronavirus (COVID-19) as described below.

Out-of-State Coverage. If your employer bought your policy in another state, contact your employer because the protections described below might not apply.

Self-Funded Coverage. If your employer self-funds the coverage, contact your employer because the protections described below might not apply.

Medicare. If you have Medicare, check with the Centers for Medicare & Medicaid Services (CMS) at (800) MEDICARE, the Medicare Rights Center at (800) 333-4114, www.medicare.gov, or the CMS fact sheet because different protections will apply.

Medicaid, Essential Plan, or Child Health Plus coverage. If you have Medicaid, Essential Plan, or Child Health Plus, check the Governor’s website https://www.governor.ny.gov/news/governor-cuomo-announces-new-directive-requiring-new-york-insurers-waive-cost-sharing or the Department of Health’s website www.health.ny.gov.

You should check your health insurance policy, or contact your insurer or employer, to understand the benefits covered under your policy. Health insurance policies typically cover the following services that you may need:

• Lab Tests
• Radiology Services
• Doctor’s Office Visits
• Telehealth Services (if offered by your provider)
• Immunizations
• Urgent Care
• Emergency Room Care
• Ambulance Services
• Inpatient Hospital Care
• Home Health Care (if hospitalization would otherwise be needed)
• Prescription Drugs

Lab Tests - Public Lab. The COVID-19 oral/nasal swab test can be done through public health laboratories, including New York State’s Wadsworth Center and the federal Centers for Disease Control and Prevention (CDC), and there is no charge to you.

Lab Tests - Other Labs. You will not have to pay your copayment, coinsurance, or deductible when you get a laboratory test to diagnose COVID-19 at other labs either.

Diagnosis. You will not have to pay your copayment, coinsurance, or deductible when you go to your doctor, a provider at another outpatient setting, an urgent care center, or an emergency room to diagnose COVID-19, including when the services are provided through telehealth.

Treatment. You may have to pay your copayment, coinsurance, or deductible for any in-person follow-up care or treatment.

Health insurers must cover diagnostic testing for COVID-19 when ordered by a licensed or authorized health care provider regardless of whether you have symptoms or may have been exposed to the virus.  You are not responsible for any deductible, copayment, or coinsurance for the COVID-19 diagnostic test.  More FAQs on this issue from the United States Department of Health and Human Services are available here.

Diagnosis. You will not have to pay your copayment, coinsurance, or deductible when you go to your doctor, a provider at another outpatient setting, an urgent care center, or an emergency room to diagnose COVID-19, including when the services are provided through telehealth. The Internal Revenue Service (IRS) recently released guidance about high deductible health plans.

Treatment. You may have to pay your copayment, coinsurance, or deductible for any in-person follow-up care or treatment.

Yes, a federal law called the CARES Act provides that tests for COVID-19 antibodies are covered without a copayment, coinsurance, or deductible when your attending healthcare provider determines that the testing is medically appropriate for you. The testing is covered regardless of whether it is performed in-network or out-of-network.

If Covered at Your Provider’s Office. Your insurer must cover your telehealth service if the service would have been covered if you went to your provider’s office or facility. However, your insurer may require telehealth services to be provided by an in-network provider.

No Cost-Sharing for COVID-19 Diagnosis. The Department of Financial Services issued a regulation so you will not have to pay your copayment, coinsurance, or deductible when you receive in-network telehealth services to diagnose COVID-19.

No Cost-Sharing for Other Treatment. The Department of Financial Services issued a regulation so that during the State of Emergency declared by Governor Cuomo for COVID-19, you will not have to pay your copayment, coinsurance, or deductible when you receive in-network telehealth services. This includes treatment of COVID-19 and any other health care services that are unrelated to COVID-19 if the services would have been covered if you went to your provider’s office or facility. Contact your insurer for more information if you have a high deductible plan.

Telephone Calls and Videos Included in Telehealth. The Department of Financial Services issued guidance on the ways you may receive telehealth services. During the State of Emergency declared by Governor Cuomo for COVID-19, telehealth includes telephone calls or video visits with your in-network provider (including when you use your smart phone or other device) when medically appropriate if all other requirements for a covered health care service are met under your policy.

Contact Your Provider. You should check with your provider to see if your provider offers telehealth services.

If Covered at Your Provider’s Office. Your insurer must cover your telehealth service for mental health or substance use disorder treatment if the service would have been covered if you went to your provider’s office or facility. However, your insurer may require telehealth services to be provided by an in-network provider.

No Cost-Sharing for Other Treatment. The Department of Financial Services issued a regulation so that during the State of Emergency declared by Governor Cuomo you will not have to pay your copayment, coinsurance, or deductible when you receive in-network telehealth services. This includes mental health and substance use disorder treatment services if the services would have been covered if you went to your provider’s office or facility. Contact your insurer for more information if you have a high deductible plan.

Contact your insurer. Let your insurer know if you were charged a deductible, copayment, or coinsurance for diagnosis of COVID-19 or for in-network telehealth services and request a refund or credit for that payment.

Contact the Department of Financial Services. If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS.

Access to Out-of-Network Provider. If there isn’t an in-network provider with the training and experience to meet your health care needs, you can go to an out-of-network provider at your in-network cost-sharing.

Ask for Approval. You must ask your insurer for approval before you see the out-of-network provider. Your insurer must make a decision within the time required by law. Learn more about decision timeframes under Appealing Decisions by HMOs and Insurers.

Appeal. If your insurer denies your request, you have a right to appeal that denial with your insurer and then to request an independent external appeal. Learn how to file an External Appeal.

Yes, the Workers’ Compensation Board adopted emergency regulations to allow telemedicine in some circumstances for social distancing purposes due to COVID-19.

The Workers’ Compensation Board issued emergency regulations regarding telemedicine under No-Fault coverage. These emergency regulations apply to all No-Fault automobile insurance claims with a date of service between March 16, 2020, through July 12, 2021.

Formulary Appeal. If you have coverage for prescription drugs, and your insurer’s formulary does not include a prescription drug that your doctor thinks you need, you can use your insurer’s formulary exception process to request coverage of an off-formulary prescription drug.

Check your Insurance Policy. Many insurance policies cover a 90-day supply of prescription drugs if you use their mail order pharmacy.

Contact Your Doctor. Your doctor or health care provider may need to write your prescription a certain way so that the pharmacy can fill a 90-day supply.

Hospital ER. You are covered for medically necessary emergency services in hospitals. You are only responsible for your in-network deductible, copayment, or coinsurance.

Large Group Coverage. If you have large group coverage that was purchased in NY (usually through your employer), you are covered for medically necessary emergency services in hospitals located in the U.S. and its territories, Canada, and Mexico.

Individual and Small Group Coverage. If you have individual coverage (including under a qualified health plan) or small group coverage that was purchased in NY, you are covered for medically necessary emergency services in hospitals worldwide.

No Preauthorization. Your insurer cannot require you to get preauthorization before you receive emergency care.

Out-of-Network Hospitals. If you go to an emergency room at an out-of-network hospital, your insurer is required to cover your care until you are stabilized, and after that, you may need to transfer to an in-network hospital for the rest of your care. Also, you are only responsible for your in-network copayment, coinsurance, or deductible for emergency services. In addition, if you go to an out-of-network New York hospital, you will only be responsible for your in-network copayment, coinsurance, or deductible for inpatient hospital services which follow an emergency room visit.

In-Network Cost-Sharing. Your insurer must protect you from surprise bills, including those for treatment of COVID-19. You are only responsible for your in-network copayment, coinsurance, or deductible if you sign an assignment of benefits form for surprise bills.

Surprise Bill For Services At In-Network Hospital or Ambulatory Surgical Center. It’s a surprise bills if an out-of-network doctor treats you and an in-network doctor was not available, or you had unforeseen services, or you didn’t know the doctor was out-of-network. It is not a surprise bill if you chose to receive services from an out-of-network doctor instead of from an available in-network doctor.

Surprise Bill If You Are Referred By Your Doctor. It’s a surprise bills if, during your in-network doctor’s office visit, an out-of-network provider treats you, or your doctor takes a specimen from you (for example, blood) and sends it to an out-of-network laboratory, or when referrals are required under your plan and your doctor refers you to an out-of-network provider. It is not a surprise bill if you signed a written consent that you knew the services were out-of-network and would not be covered by your health plan. Learn more about the protections for surprise bills.

Internal Appeal. Insurers can’t deny COVID-19 treatment as not medically necessary. If you get a denial for COVID-19 treatment, you should file a complaint with DFS. If your insurer denies any other treatment as not medically necessary, or as experimental or investigational, you can appeal the denial with your insurer. Your insurer must make a decision within the time required by law. Learn more about decision timeframes under Appealing Decisions by HMOs and Insurers.

External Appeal. If your insurer upholds a denial of coverage for treatment, you have the right to appeal to the Department of Financial Services. Learn how to file an External Appeal.

Cancellation Not Permitted. Your insurer can’t cancel or non-renew your policy because you get sick, including if you are diagnosed with COVID-19.

If you lose your insurance coverage and you are totally disabled (including as a result of COVID-19), you have the following protections if you meet the requirements below. Totally disabled generally means that you can’t engage in any work or other gainful activity due to injury or disease. For a minor, totally disabled generally means that the minor can’t, due to injury or disease, engage in substantially all of the normal activities of a person of that age who is in good health. You should read your policy to learn the specific definition that applies to you.

Individual Coverage. If you are totally disabled on the date your individual health insurance policy terminates, your insurer will continue to pay for covered services for up to 12 months, or until you are no longer disabled, if sooner. You must have received treatment for your disability before your policy ends. The extended benefits are only available to treat the condition causing your disability.

Group Coverage Terminated for Non-Payment of Premiums or You Are No Longer Eligible for Coverage. If you are totally disabled on the date your coverage terminates, your insurer will provide benefits for a hospital stay beginning, or surgery performed, within 31 days from the date your coverage ends, or until you are no longer disabled, if sooner. The hospital stay or surgery must be to treat the condition causing your disability.

Group Coverage Terminated for Loss of Employment. If you are totally disabled on the date your coverage terminates, your insurer will provide benefits for covered services during a period of total disability for up to 12 months from the date your coverage ends, or until you are no longer disabled, if sooner. The extended benefits are only available to treat the condition causing your disability. Also, your insurer is not required to extend benefits if you have coverage for the services under another group health plan.

No Premium Payments. You are not responsible for paying premiums during an extension of benefits.

Need More Information? Contact your insurer for more information about your rights if you are disabled and lose your coverage.

COBRA and Continuation of Coverage. Employers that provide group health insurance coverage must offer employees (and their dependents) who lose coverage because of a loss of employment, loss of eligibility for coverage, or reduction in hours the right to continue the coverage under the employer’s health plan. Please visit the Department of Financial Services’ resource page for information on continuing your health insurance. COBRA or continuation coverage is only available if your employer keeps the group policy after you lose your job. If your employer goes out of business or no longer provides group health insurance to employees, you cannot get COBRA or continuation benefits. However, you can get coverage through the NY State of Health: The Official Health Plan Marketplace.

Employee Pays the Premium. You or your covered dependent pay the cost of your continued health insurance. This premium may not be more than 102% of the group premium.

Employer Provides Notification. Your employer or its benefit administrator must tell you about your right to continue health insurance coverage. You have at least 60 days to elect to continue your coverage from the later of (1) the date your coverage terminates or (2) the date you are sent notice of your right to continue your coverage.

Group Contract Terminates. If your employer went out of business, you will not be able to get COBRA or continuation coverage. You will need individual coverage. The NY State of Health: The Official Health Plan Marketplace has several options for coverage, which could provide you with lower-cost or no-cost coverage depending on your income. You also have the right to buy individual coverage through the insurer that provided your group coverage, known as a “conversion” policy. Your insurer will notify you of the right to buy a conversion policy. You have 60 days to apply for this coverage.

Yes. If you are covered as a dependent on someone else’s health insurance, and you lose your coverage because you no longer qualify as a dependent (for example, due to divorce, age limit for dependent children, or death of the insured), you have your own right to continue your coverage. See Consumer Frequently Asked Questions: COBRA Coverage for more information.

Individual Coverage and Tax Credits.& You and your family have many health insurance options available through NY State of Health: The Official Health Plan Marketplace. You can quickly compare health plan options and apply for assistance that could lower the cost of health coverage.

Medicaid, Essential Plan, and Child Health Plus. You and your family may also qualify for free or low-cost coverage from Medicaid, the Essential Plan, or Child Health Plus through the Marketplace.

Special Enrollment Period. If you don’t have health insurance, you can buy individual coverage through the Marketplace until June 15 during a special enrollment period. If you lost your employer coverage, you have a separate special enrollment period to buy health insurance coverage though the Marketplace for 60 days after your loss.

Essential workers are:

A.   Individuals who are, or were, during the current state of emergency, employed as health care workers, first responders, or in any position within a nursing home, long-term care facility, or other congregate care setting, including:

• correction/parole/probation officers;
• direct care providers;
• firefighters;
• health care practitioners, professionals, aides, and support staff (e.g., physicians, nurses, and public health personnel);
• medical specialists;
• nutritionists and dietitians;
• occupational/physical/recreational/speech therapists;
• paramedics/emergency medical technicians;
• police officers;
• psychologists/psychiatrists;
• residential care program managers; and

B.   Individuals who are, or were, during the current state of emergency, employed as essential employees who directly interact with the public while working, including:

• animal care workers (e.g., veterinarians);
• automotive service and repair workers;
• bank tellers and other bank workers;
• building code enforcement officers;
• childcare workers;
• client-facing case managers and coordinators;
• counselors (e.g., mental health, addiction, youth, vocational, crisis, etc.);
• delivery workers;
• dentists and dental hygienists;
• essential construction workers at occupied residences or buildings;
• faith-based leaders (e.g., chaplains and clergy members);
• field investigators/regulators for health and safety;
• food service workers;
• funeral home workers;
• hotel/motel workers;
• human services providers;
• laundry and dry-cleaning workers;
• mail and shipping workers;
• maintenance and janitorial/cleaning workers;
• optometrists, opticians, and supporting staff;
• retail workers at essential businesses (e.g., grocery stores, pharmacies, convenience stores, gas stations, hardware stores);
• security guards and personnel;
• shelter workers and homeless support staff;
• social workers;
• teachers/professors/educators;
• transit workers (e.g., airports, railways, buses, and for-hire vehicles);
• trash and recycling workers; and
• utility workers.

An essential worker can access all outpatient mental health services without paying any cost-sharing when provided by an in-network provider.

Yes.

No.

The waiver began on May 2, 2020 and applies to any outpatient mental health service provided on or after that date. In addition, cost-sharing for all in-network telehealth services, including for mental health services, have been waived since March 16, 2020.

Yes.

No. The waiver does not apply to Medicare plans (including Medicare Advantage).

Yes, the waiver applies to all individuals who are, or were, essential workers during the state of emergency declared by Governor Cuomo on March 7, 2020.

You should tell your provider you are an essential worker. Insurers are required to advise their network providers not to collect any cost-sharing from essential workers.

Contact your insurer to request a refund or credit for that payment. You can also contact the Department of Financial Services. If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS.

No.  If you visit a participating provider, the provider may not charge you for PPE used during the visit.  You are only responsible for your in-network cost-sharing amount (such as a copayment, coinsurance, or deductible) as described in your health insurance policy for covered services.

When you visit a participating provider, the provider should not charge you for PPE used during a visit.  But if they do, you should contact your insurer to let them know you have been charged for PPE and request a refund.  If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS.

If your participating provider requires you to sign a consent form and you pay charges for PPE, you should contact your insurer to request a refund.  If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS.

NY Insurance Coverage. If you have individual or group health insurance coverage that you or your employer bought in New York, including through the NY State of Health Marketplace or the New York State Health Insurance Program (NYSHIP) for public employees, COVID-19 vaccines are covered.

Out-of-State Coverage. If your employer bought your policy in another state, contact your employer for details.

Self-Funded Coverage. If your employer self-funds the coverage, contact your employer for details.

Medicare. COVID-19 vaccines are covered by Medicare. For more information, visit the Centers for Medicare & Medicaid Services (CMS) Medicare website or call (800) MEDICARE or the Medicare Rights Center at (800) 333-4114.

Medicaid, Essential Plan, or Child Health Plus Coverage. COVID-19 vaccines are covered by Medicaid, Essential Plan, and Child Health Plus. For more information, visit the Department of Health’s website.

No. You will not have to pay your copayment, coinsurance, deductible, or any other charges, including a charge for an office visit or a facility fee, for a COVID-19 vaccine or its administration. However, if you get services unrelated to your COVID-19 vaccine at the same time, you may get charged cost-sharing for those other unrelated services.

No. You will not have to pay your copayment, coinsurance, or deductible even if you have a HDHP, since vaccines are preventive services which are not subject to the deductible or other cost-sharing.

Contact your insurer. Let your insurer know if you were charged for a COVID-19 vaccine and request a refund for that payment.

Contact the Department of Financial Services. If you are unable to resolve the issue after contacting your insurer, file a complaint with DFS.

You should not be charged if you receive the vaccine from an out-of-network provider during the federal Public Health Emergency. Check the CMS website to find out if the federal Public Health Emergency is still active.

However, once the federal Public Health Emergency ends, you may be required to obtain the vaccine from a provider who participates with your insurance.

No. Providers in the CDC COVID-19 Vaccination Program must give you the vaccine even if you are uninsured. Providers can get reimbursed for COVID-19 vaccine administration through the U.S. Human Resources & Services Administration COVID-19 Relief Fund Program. Providers can visit the HRSA website for more information about this program.