Coronavirus (COVID-19) information: Health Insurance FAQs

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.

Telephone Calls and Videos Included in Telehealth. The Department of Financial Services issued guidance on the ways you may receive telehealth services. The Department issued an emergency regulation to require that 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.

Contact your insurer. Let your insurer know if you were charged a deductible, copayment, or coinsurance for diagnosis of COVID-19 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 October 10, 2022.

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.  

You must sign a Surprise Bill Certification Form if:

• Your in-network doctor referred you to an out-of-network provider; or
• An out-of-network provider treated you at an in-network hospital or ambulatory surgical facility before January 1, 2022. The form is not required for services provided on or after January 1, 2022 at an in-network hospital or ambulatory surgical facility, but it is recommended.

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

Generally, if you are the employee or covered dependent, you must pay the cost of continued health insurance. Your premium may not be more than 102% of the group premium. You may be eligible for a temporary COBRA premium subsidy through the American Rescue Plan of 2021. Please see the FAQs on the American Rescue Plan below for more information.

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.

Yes.  Starting January 15, 2022, health plans must cover at-home over-the-counter COVID-19 diagnostic tests authorized by the U.S. Food and Drug Administration (FDA).  Your health plan must cover eight tests per month for each individual covered by your plan.

Health plans must cover tests you purchase in person or online.  Depending on where you purchase the test, you may get the test at the point of sale for free, or you may have to pay for the test up-front and submit a claim to your insurer for reimbursement.  Health plans can set up a network of convenient locations in their service area (like pharmacies or other retailers) where you can purchase at-home tests for free, rather than paying out-of-pocket for tests and submitting claims for reimbursement.  You should contact your health plan to find out where you can obtain over-the-counter COVID-19 tests at no cost or whether you will need to submit a claim for reimbursement after you purchase a test.

The test will either be free at the point of sale, if your health plan has an arrangement with pharmacies or other retailers to provide for direct coverage, or you will be reimbursed if you have to pay for the tests up front. Be sure to keep your receipt if you need to submit a claim to your insurance company for reimbursement.  You should contact your health plan to find out whether there are locations in your area where you can obtain tests at no cost, or whether you will need to purchase a test and then request reimbursement.

If your health plan has set up a network of preferred providers at which you can obtain a test with no out-of-pocket expense, you can still obtain tests from other retailers outside that network.  Insurance companies are required to reimburse you at a rate of up to $12 per individual test (or the cost of the test, if less than $12).

Health plans are not required to provide coverage of testing (including an at-home over-the-counter COVID-19 test) that is for employment purposes.

If you test positive for COVID-19, you have to isolate in accordance with Department of Health guidelines.  If you need documentation of your need to isolate for school or work, you can fill out an Affirmation of Isolation Form instead of getting an Order of Isolation from the state or county Department of Health.

Visit COVIDtests.gov to order your free at-home over-the-counter COVID-19 tests.  Each household can order four tests.

For more information regarding coverage of at-home COVID-19 tests, visit the CMS At-Home Over-The-Counter COVID-19 Test website.

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. (Please note that grandfathered large group plans are not required to cover vaccines for persons aged 19 or older, though federal law prohibits providers from billing you for the COVID-19 vaccine or its administration. Ask your employer whether your large group plan is grandfathered.)

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.