What are the out-of-pocket costs for COVID-19 treatment, if any?

Executive Summary

• If you have Commercial (non-grandfathered, non-self-funded), Medicare Advantage or Medicaid, insurers have been waiving cost-sharing for COVID-19 treatment (the largest insurers so far have set time frames and extensions until at least end of 2020)
• If you are on traditional Medicare or in a Commercial Obamacare-compliant health plan and do not have cost-sharing waived, you may have to pay out-of-pocket.
  • Pneumonia has been used to estimate out-of-pocket costs and this could start at $1,300 depending on complications (e.g. ventilator usage), deductible amount based plan type (large group, small business, individual); and balance/surprise billing is estimated to occur for one in five cases
• If you are uninsured, the Provider Relief Fund can reimburse your provider if they apply for it

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The American media has heavily focused on coverage and accessibility to COVID-19 testing and vaccines, but I saw little coverage on COVID-19 treatment should you unfortunately need it. I looked into what it might cost you out-of-pocket for the entire treatment.

The Kaiser Family Foundation laid out how traditional Medicare would cover hospital stays but beneficiaries would need to pay deductibles ($1,484), whereas it is recommended for Medicare Advantage plans to waive cost-sharing. They also projected COVID-19 hospital cost using historical claims on pneumonia for private (employer-sponsored) health insurance (published March 13, 2020). They estimate out-of-pocket costs exceeding $1,300 but private insurers have been waiving cost-sharing requirements so far. Medicaid patients have no cost-sharing for COVID-19 treatment per the CARES Act. If you are uninsured, the Provider Relief Fund could reimburse providers for treatment but that is up to the provider to apply for it, otherwise, you may be liable for the bill.

The LA Times reported a situation where COVID-19 treatment became a huge financial burden ($42,000 in out-of-pocket) because the individual had a grandfathered self-insured plan which does not have an out-of-pocket maximum limit (grandfathered plans do not have to comply with the Affordable Care Act/Obamacare out-of-pocket maximum limit elimination and self-insured plans are not subject to the same federal regulations). The article compared how another person with a similar total cost of care but an out-of-pocket maximum limit ended up with out-of-pockets costs around $1,000.

The American Health Insurance Plans (AHIP) has compiled an inventory of what insurers are doing in response to the pandemic (visited March 1st, 2021). Here are the highlights from the five major insurers on COVID-19 treatment cost-sharing (deductibles, co-pay, co-insurance) or out-of-pocket costs. They are essentially are waiving cost-sharing but the date ranges and extensions vary.

• Aetna previously waived cost-sharing for inpatient admission treatment for COVID-19 (announced September 23rd, 2020 and effective until December 31st, 2020 for Commercial and Medicare Advantage.
• United Healthcare has extended its COVID-19 treatment cost-sharing waiver for Individual and Group during the month of January 2021, and for Medicare Advantage there is no cost-sharing until March 31st, 2021.
• Cigna is waiving cost-sharing for COVID-19 treatments until February 15, 2021, but that is only mentioned on the AHIP website and not date-stamped on Cigna’s website itself.
• Humana is waiving cost-sharing for COVID-19 treatment for all lines of business (Commercial, Medicare Advantage and Supplement, Medicaid) with not definite expiration date.
• Anthem has extended its COVID-19 treatment cost-sharing waiver until of January 31, 2021.