FAQs on Medicare Coverage and Costs Related to COVID-19 Testing and Treatment
More than 60 million people ages 65 and older and younger adults with long-term disabilities are covered by Medicare. Due to their older age and higher likelihood of having serious medical conditions than younger adults, virtually all Medicare beneficiaries are at greater risk of becoming seriously ill if they are infected with the new coronavirus that causes COVID-19. COVID-19 is an infectious respiratory disease, which currently has no vaccine or cure. Diagnosis of COVID-19 is confirmed through testing, and treatment varies based on the severity of illness.
These FAQs review current policies for Medicare coverage and costs associated with testing and treatment for COVID-19, including regulatory issued by the Centers for Medicare & Medicaid Services (CMS) since the declaration of the public health emergency (first issued on January 31, 2020 and renewed on April 21, 2020), and legislative changes adopted in three recent bills: the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, enacted on March 6, 2020 (Public Law 116-123); the Families First Coronavirus Response Act, enacted on March 18, 2020 (Public Law 116-127); and the Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted on March 27, 2020 (Public Law 116-136).
Does Medicare cover testing for COVID-19?
Yes, testing for COVID-19 is covered under Medicare Part B. Under rules announced on April 30, 2020, an order from a beneficiary’s treating physician is no longer required for COVID-19 testing to be covered under Medicare, which will better enable beneficiaries to use community testing sites, such as drive-through testing at hospital off-site locations. Medicare will also cover serology tests that can determine whether an individual has been infected with SARS-CoV-2, the virus that causes COVID-19, and developed antibodies to the virus. Medicare Advantage plans are required to cover all Medicare Part A and Part B services, including COVID-19 testing.
How much do Medicare beneficiaries pay for COVID-19 testing?
Medicare beneficiaries who get tested for COVID-19 are not required to pay the Part B deductible or any coinsurance for this test, because clinical diagnostic laboratory tests are covered under traditional Medicare at no cost sharing. Beneficiaries will also not face cost sharing for the COVID-19 serology test, since it is considered to be a diagnostic laboratory test. (Under traditional Medicare, beneficiaries typically face a $198 deductible for Part B services and coinsurance of 20 percent.) A provision in the Families First Coronavirus Response Act also eliminates beneficiary cost sharing for COVID-19 testing-related services, including the associated physician visit or other outpatient visit (such as hospital observation, E-visit, or emergency department services). A testing-related service is a medical visit furnished during the emergency period that results in ordering or administering the test. The law also eliminates cost sharing for Medicare Advantage enrollees for both the COVID-19 test and testing-related services, and prohibits the use of prior authorization or other utilization management requirements for these services.
Does Medicare cover treatment for COVID-19?
People who get seriously ill from the virus may need a variety of inpatient and outpatient services. Medicare covers inpatient hospital stays, skilled nursing facility (SNF) stays, some home health visits, and hospice care under Part A, and outpatient services, including physician visits, emergency ambulance transportation, and emergency room visits, under Part B. If an inpatient hospitalization is required for treatment of COVID-19, this treatment will be covered for Medicare beneficiaries, including beneficiaries in traditional Medicare and those in Medicare Advantage plans. Beneficiaries who need post-acute care following a hospitalization have coverage of SNF stays, but Medicare does not cover long-term services and supports, such as extended stays in a nursing home.
How much do Medicare beneficiaries pay for COVID-19 treatment?
Beneficiaries who are admitted to a hospital for treatment would be subject to the Medicare Part A deductible of $1,408 per benefit period in 2020. Part A also requires daily copayments for extended inpatient hospital and SNF stays. For extended hospital stays, beneficiaries would pay a $352 copayment per day (days 61-90) and $704 per day for lifetime reserve days. If a patient is required to be quarantined in the hospital, even if they no longer meet the need for acute inpatient care and would otherwise by discharged, they would not be required to pay an additional deductible for quarantine in a hospital. Traditional Medicare beneficiaries who need post-acute care following a hospitalization would face copayments of $176 per day for extended days in a SNF (days 21-100). For COVID-19 treatment-related outpatient services covered under Part B, there is a $198 deductible in 2020 and 20 percent coinsurance that applies to most services, including physician visits and emergency ambulance transportation.
While most traditional Medicare beneficiaries (81% in 2016) have supplemental coverage (such as Medigap, retiree health benefits, or Medicaid) that covers some or all of their cost-sharing requirements, more than 6 million beneficiaries lacked supplemental coverage in 2016, which places them at greater risk of incurring high medical expenses or foregoing medical care due to costs. Medicare does not have an out-of-pocket limit for services covered under Medicare Parts A and B.
Cost-sharing requirements for beneficiaries in Medicare Advantage plans vary across plans. Medicare Advantage plans often charge daily copayments for inpatient hospital stays, emergency room services, and ambulance transportation. Medicare Advantage enrollees can be expected to face varying costs for a hospital stay depending on the length of stay and their plan’s cost-sharing amounts. According to CMS guidance, Medicare Advantage plans may waive or reduce cost sharing for COVID-19-related treatments, and most Medicare Advantage insurers have announced that they are temporarily waiving such costs, but this is not required. Plans may also waive prior authorization requirements that would apply to services related to COVID-19.
If a vaccine is approved for COVID-19, would it be covered by Medicare?
Medicare Part B covers certain preventive vaccines (influenza, pneumococcal, and Hepatitis B), and these vaccines are not subject to Part B coinsurance and the deductible. Medicare Part B also covers vaccines related to medically necessary treatment. For traditional Medicare beneficiaries who need these medically necessary vaccines, the Part B deductible and 20 percent coinsurance would apply. Based on a provision in the CARES Act, if a vaccine becomes available for COVID-19, Medicare is required to cover this vaccine under Part B with no cost sharing for Medicare beneficiaries for the vaccine or its administration; this applies to beneficiaries in both traditional Medicare and Medicare Advantage plans.
What telehealth benefits are covered by Medicare, and how much do beneficiaries pay?
Based on new waiver authority included in the Coronavirus Preparedness and Response Supplemental Appropriations Act (and as amended by the CARES Act) the HHS Secretary has waived certain restrictions on Medicare coverage of telehealth services for traditional Medicare beneficiaries during the coronavirus public health emergency. The waiver, effective for services starting on March 6, 2020, allows beneficiaries in any geographic area to receive telehealth services; allows beneficiaries to remain in their homes for telehealth visits reimbursed by Medicare; allows telehealth visits to be delivered via smartphone with real-time audio/video interactive capabilities in lieu of other equipment; and removes the requirement that providers of telehealth services have treated the beneficiary receiving these services in the last three years. A separate provision in the CARES Act allows federally qualified health centers and rural health clinics to provide telehealth services to Medicare beneficiaries during the COVID-19 emergency period.
Telehealth services are not limited to COVID-19 related services, and can include regular office visits, mental health counseling, and preventive health screenings. During the emergency period, Medicare will also cover some evaluation and management, behavioral health, and patient education services provided to patients via audio-only telephone.
Separately from the time-limited expanded availability of telehealth services, traditional Medicare also covers brief, “virtual check-ins” via telephone or captured video image, and E-visits, for all beneficiaries, regardless of whether they reside in a rural area. These visits are more limited in scope than a full telehealth visit, and there is no originating site requirement.
Medicare covers all types of telehealth services under Part B, so beneficiaries in traditional Medicare who use these benefits are subject to the Part B deductible of $198 in 2020 and 20 percent coinsurance. However, the HHS Office of Inspector General is providing flexibility for providers to reduce or waive cost sharing for telehealth visits during the COVID-19 public health emergency.
Medicare Advantage plans are able to offer additional telehealth benefits not covered by traditional Medicare, including telehealth visits for beneficiaries provided to enrollees in their own homes, and services provided outside of rural areas. Medicare Advantage plans have flexibility to waive certain requirements with regard to coverage and cost sharing in cases of disaster or emergency, such as the COVID-19 outbreak. In response to the coronavirus pandemic, CMS has advised plans that they may waive or reduce cost sharing for telehealth services, as long as plans do this uniformly for all similarly situated enrollees.
Can Medicare beneficiaries get extended supplies of medication?
The Department of Homeland Security recommends that, in advance of a pandemic, people ensure they have a continuous supply of regular prescription drugs. In light of the coronavirus pandemic, a provision in the CARES Act requires Part D plans (both stand-alone drug plans and Medicare Advantage drug plans) to provide up to a 90-day (3 month) supply of covered Part D drugs to enrollees who request it during the public health emergency. (Typically Medicare Part D plans place limits on the amount of medication people can receive at one time and the frequency with which patients can refill their medications.)
According to CMS, for drugs covered under Part B, Medicare and its contractors make decisions locally and on a case-by-case basis as to whether to provide and pay for a greater-than-30 day supply of drugs.
What happens if Medicare beneficiaries in private plans need to receive care from out-of-network providers?
Plans that provide Medicare-covered benefits to Medicare beneficiaries, including stand-alone prescription drug plans and Medicare Advantage plans, typically have provider networks and limit the ability of enrollees to receive Medicare-covered services from out-of-network providers, or charge enrollees more when they receive services from out-of-network providers or pharmacies. In light of the declaration of a public health emergency in response to the coronavirus pandemic, certain special requirements with regard to out-of-network services are in place. During the period of the declared emergency, Medicare Advantage plans are required to cover services at out-of-network facilities that participate in Medicare, and charge enrollees who are affected by the emergency and who receive care at out-of-network facilities no more than they would face if they had received care at an in-network facility.
Part D plan sponsors are also required to ensure that their enrollees have adequate access to covered Part D drugs at out-of-network pharmacies when enrollees cannot reasonably be expected to use in-network pharmacies. Part D plans may also relax restrictions they may have in place with regard to various methods of delivery, such as mail or home delivery, to ensure access to needed medications for enrollees who may be unable to get to a retail pharmacy.
Are there any special rules for Medicare coverage for skilled nursing facility or nursing home residents related to COVID-19?
In response to the national emergency declaration related to the coronavirus pandemic, CMS is waiving the requirement for a 3-day prior hospitalization for coverage of a skilled nursing facility (SNF) for those Medicare beneficiaries who need to be transferred as a result of the effect of a disaster or emergency. For beneficiaries who may have recently exhausted their SNF benefits, the waiver from CMS authorizes renewed SNF coverage without first having to start a new benefit period.
Nursing home residents who have Medicare coverage and who need inpatient hospital care, or other Part A, B, or D covered services related to testing and treatment of coronavirus disease, are entitled to those benefits in the same manner that community residents with Medicare are.
Medicare establishes quality and safety standards for nursing facilities with Medicare beds, and has issued guidance to facilities to help curb the spread of coronavirus infections. This guidance directs nursing homes to restrict visitation by all visitors and non-essential health care personnel (except in compassionate care situations such as end-of-life), cancel communal dining and other group activities, actively screen residents and staff for symptoms of COVID-19, and use personal protective equipment (PPE). These new rules do not apply to assisted living facilities, which are regulated by states.
Analysis shows considerable variation across states in terms of regulations to protect against the spread of coronavirus infections in nursing facilities and assisted living facilities. Individual states differ in whether they address all, some, or none of the recommendations related to visitation, staff screening, and use of PPE in both nursing facilities and assisted living facilities, as well as whether they require or simply recommend facility adherence to these measures. Many states have weaker standards for assisted living facilities than for nursing facilities.