COVID-19 and Medicare Coverage. What You Need to Know.

Early Saturday, March 14, the House passed legislation (H.R. 6201) that would waive all beneficiary cost sharing for coronavirus testing and the associated doctor’s office visit. A Senate vote is expected soon. We will update this article to reflect any final policy changes.

As the number of cases of COVID-19 (also called coronavirus) increases, so does the importance of programs like Medicare in helping older adults, people with disabilities, and their families build and maintain their health and economic security. Accordingly, policymakers are taking critical steps to ensure program preparedness, keep beneficiaries and the public informed, and facilitate timely access to appropriate care.

The Centers for Medicare & Medicaid Services (CMS) is working to address the spread of the disease and inform people with Medicare about the services that Medicare covers. The Centers for Disease Control and Prevention (CDC) has identified older adults and people with serious chronic medical conditions like heart disease, diabetes, and lung disease as being at higher risk from the virus.

In general, Medicare covers medically necessary items and services that a beneficiary receives from a provider who accepts Original Medicare or is in-network for the beneficiary’s Medicare Advantage Plan. Medicare Advantage Plans must cover everything that Original Medicare does, but they can do so with different costs and restrictions.

• Coronavirus testing
  • Coronavirus testing will be covered under Medicare Part B as a clinical laboratory test. A beneficiary’s doctor can bill Medicare for this test beginning April 1, 2020 for testing provided after February 4, 2020. If a beneficiary has Original Medicare, they will owe nothing for the laboratory test (no deductible or coinsurance) as long as they see a provider who accepts Original Medicare. Note that a beneficiary may still owe cost-sharing for other services they get during the doctor’s office visit. If a beneficiary has a Medicare Advantage Plan, they should contact their plan to learn about its costs and coverage rules.
• Coronavirus vaccine
  • There is currently no vaccine for coronavirus. If a coronavirus vaccine is developed, it will be covered under Medicare Part D. All Part D plans will be required to cover the vaccine. How much a beneficiary will owe for the vaccine will depend on costs set by their drug plan.
• Prescription refills
  • If a beneficiary wants to refill their prescriptions early so that they have extra medication on hand, they should contact their Part D drug plan to learn what is covered. Their plan may require extra approval before it covers early refills, and not all prescriptions can be refilled in advance.
    Note: If a beneficiary takes medications that are covered by Part B, they should ask their doctor for advice.
• Inpatient hospital care
  • Inpatient hospital care is covered under Medicare Part A, and standard coverage rules and cost-sharing apply. Medicare typically covers a semi-private room, but it should cover a private room when it is medically necessary. For example, if a beneficiary needs a private room in order to be quarantined, you should not be asked to pay an additional cost for the private room. If a beneficiary has a Medicare Advantage Plan, they should contact their plan to learn about its costs and coverage rules.
• Outpatient hospital care
  • Outpatient hospital care is covered under Part B, and standard coverage rules and cost-sharing apply. If a beneficiary receives observation services at a hospital, they are considered an outpatient—even if they have a room or stay overnight. Whether a beneficiary is an inpatient or outpatient is important because, depending on their situation, a beneficiary may be required to have an inpatient stay before Medicare will cover skilled nursing facility (SNF) care.
• Skilled nursing facility (SNF) care
  • Medicare Part A generally only covers SNF care if someone was a hospital inpatient for three days in a row before entering the SNF. This is known as the three-day qualifying hospital stay. At this time, Medicare has removed the three-day qualifying hospital stay requirement for beneficiaries who experience dislocations or are otherwise affected by the coronavirus public health emergency.
  • According to Medicare, this waiver includes but is not limited to beneficiaries who:
    • Need to be transferred to a SNF, for example, due to nursing home evacuations or to make room at local hospitals
    • Need SNF care as a result of the current public health emergency, regardless of whether they were previously in the hospital

    Medicare is also changing other SNF coverage requirements. Typically, Medicare Part A covers up to 100 days of SNF care each benefit period. A benefit period begins when a beneficiary is admitted to a hospital as an inpatient, or to a SNF, and it ends when they have been out of a SNF or hospital for at least 60 days in a row. The 100 days of covered SNF care reset at the beginning of a new benefit period. Beneficiaries who are unable to start a new benefit period because of the public health emergency can get another 100 days of covered SNF care without having to begin a new benefit period.
    Also note that Medicare is working with SNFs to help limit the spread of COVID-19.

• Physicians’ services in the home
  • Part B covers services a beneficiary receives from a physician (or other provider, such as a registered nurse) who visits their home. Part B also covers some services that are not face-to-face with a doctor, such as check-in phone calls or assessment using an online patient portal. Virtual check-ins can be used to assess whether a beneficiary should go to their doctor’s office for an in-person visit.
• Telehealth services
  • A telehealth service is a full visit with a provider using telephone or video technology. Medicare generally only covers telehealth in limited situations for certain beneficiaries, but it has expanded coverage and access during the public health emergency. Starting March 6, 2020, Medicare covers hospital and doctors’ office visits, mental health counseling, preventive health screenings, and other visits via telehealth for all beneficiaries and in settings that include the beneficiary’s home. Health care providers who can offer these telehealth services include doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Standard cost-sharing may apply, but note that a provider can choose not to charge the beneficiary for these services. If a beneficiary has a Medicare Advantage Plan, they should contact their plan to learn about its costs and coverage rules.

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