What If You Get Sick?

You’ve seen the headlines about the number of cases, deaths, cancelations, and travel restrictions brought about by the Coronavirus disease 2019 or “COVID-19.” The big concern for seniors: What happens if you get sick? How will Medicare cover you?

In “normal times,” testing and treatment for an illness is considered medically necessary and reasonable. For those on Original Medicare, the Part A and Part B cost sharing would apply, which a Medicare supplement or Medigap policy would help cover. Medicare Advantage and Part D drug plan enrollees would also face the plan’s requisite cost sharing and coverage rules. 

However, because of the impact of this virus, these are far from normal times. On March 13, President Trump declared a national emergency. Here’s a summary of the impact of that declaration on Medicare.

Medicare Advantage 

A Medicare Advantage plan must cover the same services that Medicare Part A and Part B cover, subject to the plan’s coverage rules (network, referrals, prior authorization) and cost sharing. However, while the emergency declaration remains in effect, federal regulations detail special requirements. Medicare Advantage plans must:

  • Waive, in full, requirements for gatekeeper referrals, where applicable.
  • Cover services that are provided at non-contracted (out-of-network) facilities.
  • Provide the same cost sharing as if the service or benefit had been furnished at a plan-contracted (in-network) facility. 
  • Make changes that benefit enrollees effective immediately, without the 30-day notification requirement.

In a recent memo, the Centers for Medicare and Medicaid Services (CMS) advised that Medicare Advantage plans may:

  • Waive or reduce cost-sharing for laboratory tests, telehealth benefits or other services to address the outbreak.
  • Waive prior authorization requirements.
  • Provide telehealth services to plan members in their homes.

Part D prescription drug coverage

Whether you have drug coverage through a stand-alone drug plan or included in a Medicare Advantage plan, CMS’ recent memo notes these actions that a Part D sponsor can take:

  • Waive prescription refill limits to avoid disruption. 
  • Reimburse members for prescriptions filled at an out-of-network pharmacy.
  • Relax restrictions on home or mail delivery of prescription drugs.
  • Waive prior authorization requirements for any Part D drugs to treat or prevent COVID-19, if or when such drugs are identified.

(Note: The CMS memo identified actions that Medicare Advantage and Part D drug plans may take. Check with your plan if you have questions.)

Original Medicare 

Those who have Original Medicare should know these points.

  • Part A, hospital insurance, will cover inpatient stays in a hospital and skilled nursing facility. These stays will be subject to the cost sharing. In a recent memo, CMS said a beneficiary should not pay more for a single room if quarantined.
  • Medicare Part B, medical insurance, will cover the test to diagnose Coronavirus. There will be no copayment for those who have this test after February 4, 2020. Medicare will also cover outpatient treatment, which will be subject to the usual cost sharing.
  • Part B also covers some services that are not face-to-face with a doctor, such as check-in phone calls or assessments using an online patient portal.
  • Telehealth: CMS recently announced that as of March 6, Medicare will pay for office, hospital, and other visits furnished via telehealth across the country and including in homes. This major expansion of services will be in effect for the duration of the public health emergency. The memo notes that the Medicare deductible and coinsurance and deductible would generally apply. However, providers will have the flexibility to waive or reduce the cost sharing.  

A Medigap policy can help pay for costs that Part A and Part B do not cover in these situations.  

Protect yourself

We all know that the best treatment is prevention. Since this virus is hitting seniors exceptionally hard, take as many precautions as you can to protect yourself. Medicare has published several tips, specific to the concerns related to the virus. Here are some that should be part of your life every day.

  • Wash your hands often with soap and water for at least 20 seconds, especially after being out in public, blowing your nose, coughing, or sneezing.
  • Cover your mouth and nose with a tissue when you cough or sneeze or use the inside of your elbow.
  • Avoid touching your face, nose and eyes.
  • Stay home if you are sick. 
  • Avoid close contact with people who are sick.

The coronavirus has been called “novel” because it has never been detected prior to this outbreak. As a result, we are going through this journey for the first time. Caution and common sense can protect you and your loved ones. And according to the head of the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci, ”That’s the reason why the kinds of things we’re doing that may seem like an over-reaction will keep us away from that worst-case scenario.”

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