Insurance Coverage and COVID-19

There is no cost for the vaccine, itself. A vaccination provider may charge an administration fee for giving you the shot, but if you have private insurance or are enrolled in a public insurance program such as Medicare or Medicaid, the vaccination provider would need to send the bill to your insurer. Vaccination providers are not allowed to charge you the administration fee when you are getting your shot or to send you a bill for the fee afterwards. Also, Medicare, Medicaid, and most types of private insurance are not allowed to bill you for any portion of the administration fee in the form of a copay, coinsurance, or deductible.

However, if you use a grandfathered health plan, a short-term limited-duration insurance policy, or an "excepted benefits" policy to cover your vaccination visit, then the insurer may be able to bill you for some portion of the administration fee. If you will be using one of these types of insurance for your vaccination, you should check your policy terms to see what you might end up paying and contact your insurer if you have further questions. Regardless, no one can be denied a vaccine if they are unable to pay a vaccine administration fee.

Individuals aware of any potential violations of these requirements are encouraged to report them to the Office of the Inspector General, U.S. Department of Health and Human Services, by calling 1-800-HHS-TIPS or the website TIPS.HHS.GOV.

For more information please visit:

• COVID-19 Vaccine Provider Requirements - CDC.gov
• COVID-19 Vaccine for Uninsured Individuals - HHS.gov

Depending on the circumstances, the testing provider might bill you directly or they might bill your insurance carrier. Regardless of who receives the bill, your insurance carrier is required by law to cover the full cost of your test and its administration as long as you received the test based on an individualized clinical assessment from a licensed or authorized health care provider. Contact your insurance carrier if you have questions about your coverage.

The testing site should not ask you for payment at the time of the test. If you have insurance, the testing site may ask for that information and bill your insurance. The Families First Coronavirus Response Act generally prohibits private health insurance coverage or group health plans from imposing cost-sharing on both the test itself and the health care provider’s administration of the test, as long as the purpose of the testing is for your individualized diagnosis or treatment of COVID-19. Additionally, health care providers who have received federal funds from the Provider Relief Fund are contractually prohibited from balance billing you for the test or its administration, even if they are out-of-network for your insurance plan. However, health insurance plans are not generally required to provide coverage of COVID-19 testing for public surveillance or employment purposes. Short-term, limited duration insurance policies and “excepted benefits” policies may subject members to some portion of the provider’s fee.

If you do not have insurance, regardless of citizenship or immigration status, the provider may bill the Illinois HFS COVID Portal or the federal HRSA COVID-19 Uninsured Program. Providers who participate in, and are reimbursed from these programs, for qualified COVID-19 related services rendered to you, are not allowed to collect any additional fees.

Regardless of your insurance status, if you experience or witness any potential violations of this requirement you can report the matter to the Office of the Inspector General, U.S. Department of Health and Human Services, by calling 1-800-HHS-TIPS or the website TIPS.HHS.GOV. If you are a Medicaid customer or are uninsured and you have been asked to pay out of pocket for a COVID-19 test, please call HFS at 877-805-5312 and press 9 for assistance.

For information about coverage of over-the-counter at-home tests, please visit the “FAQs about Insurance Coverage of Over-the-Counter At-Home Coronavirus (COVID-19) Tests” section of this page.

For more information about testing sites, please visit: https://dph.illinois.gov/covid19/testing/faq.html.

No. The Illinois Insurance Code prohibits health insurance issuers from charging higher out-of-pocket expenses to an enrollee who sees an out-of-network provider at an in-network facility if there are no in-network providers available. However, if you willfully choose a non-network provider when an in-network provider is readily available, you might be subject to higher out-of-pocket expenses.

Insurance carriers must cover emergency services for an emergency medical condition at in-network levels regardless of which provider performs the services. Emergency services include transportation services, such as ambulance services, as well as inpatient and outpatient hospital services that are needed to evaluate or stabilize the patient. Many individuals who have contracted COVID 19 have not required emergency services. Still, exceptional circumstances may arise.

The CDC and American Red Cross recommend that households maintain at least a 30-day supply of any prescription drugs used by household members at all times to prepare for unexpected events. The Department has encouraged health insurance carriers to do all that they can to allow people to get more than a 30-day supply of a prescription drug at one time, subject to the limits of the prescription written by the treating healthcare provider. The Department does not recommend stockpiling prescriptions that are highly susceptible to abuse, such as opioids that may be restricted to 7-day prescriptions.

No. The Illinois Insurance Code prohibits individual or group accident and health insurance carriers from imposing any pre-existing condition exclusions, including in connection with COVID 19. Federal law and state regulations provide protections against preexisting condition exclusions in health insurance coverage, as well. However, preexisting condition consumer protections do not apply to short-term, limited-duration health insurance coverage or excepted benefit policies.

View up to date information on how Illinois is handling COVID 19 from the Illinois Department of Public Health

Yes. If you have questions regarding health insurance and HMO inquiries, please call the Illinois Department of Insurance at (877) 527-9431.

Yes. If you have questions regarding Medicare beneficiaries and caregiver inquiries, please call CMS at (800) 548-9034.

This guidance applies to OTC at-home COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA). Click here for a complete list of tests approved by the FDA: https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/in-vitro-diagnostics-euas-antigen-diagnostic-tests-sars-cov-2.

Most individual and group health plans are subject to this guidance and required to provide OTC at-home COVID-19 tests at either no upfront cost or a set reimbursement amount. Short-term limited duration plans, and excepted benefit health plans, such as dental or vision plans, are not subject to this guidance. https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/aca-part-51.pdf.

Self-insured plans are subject to the federal guidance, however, enforcement for those plans falls under the Department of Labor for the self-insured plans of private employers and under the Department of Health and Human Services for non-Federal governmental employers, such as state and local governments. Consumers who have concerns about the compliance of their private self-insured plan with the federal requirements may contact the Department of Labor at askebsa.dol.gov or by calling toll free at 1-866-444-3272. For a self-insured non-Federal governmental plan, contact the Health Insurance Assistance Team of the U.S. Center for Consumer Information and Insurance Oversight at (888) 393-2789 or phig@cms.hhs.gov.

Information about State of Illinois Employee & Retiree Health Plans can be found here:

https://mybenefits.illinois.gov/Article/Print/SOI-COVID-19-Information.

People without insurance can get free OTC at-home COVID-19 tests from some community health centers. The United States Department for Health and Human Services ("HHS") has established more than 10,000 free community-based pharmacy testing sites around the country. https://www.hhs.gov/coronavirus/community-based-testing-sites/index.

Additional information about testing resources for people without health insurance are available here:

https://www.hhs.gov/coronavirus/covid-19-care-uninsured-individuals/index.html.

Information about how to obtain OTC at-home COVID-19 tests under Medicare can be found here:

https://www.cms.gov/files/document/covid-19-over-counter-otc-tests-medicare-frequently-asked-questions.pdf.

Yes.

Health plans are required to cover no less than 8 OTC at-home COVID-19 tests per covered individual per month. For example, a family of four, all on the same plan, would be able to get up to 32 of these tests covered per month.

Additionally, there is no limit on the number of tests, including at-home tests, that are covered if those tests are ordered or administered by a health care provider following an individualized clinical assessment, including for those who may need them due to underlying medical conditions.

IMPORTANT NOTE: Tests may be packaged individually or with multiple tests in one box. Plans are required to cover 8 tests per covered individual per month, regardless of how they are packaged and distributed. (For example, 4 boxes that each contain 2 tests would be equivalent to 8 boxes that only contain one test.)

You do not need a physician's referral or prior authorization to obtain coverage for the 8 OTC at-home COVID-19 tests per month, per individual.

There is generally no limit on the number of COVID-19 tests, including OTC at-home COVID-19 tests, that must be covered when ordered by a healthcare provider based upon an individualized clinical assessment. If you have questions about your coverage, the Department recommends you contact your health plan.

IMPORTANT NOTE: Health plans are not required to provide coverage of testing (including an OTC at-home COVID-19 test) that is for employment purposes and may require an attestation that tests are for personal use only.

Because the process will vary by plan, we recommend you contact your health plan prior to purchasing the OTC at-home COVID-19 test if you have questions about your coverage. If you are charged for your test, keep your receipt and/or UPC code and submit a claim to your health plan for reimbursement. Plans may have options for you to obtain tests at no upfront costs. Some issuers may also implement direct-to-consumer shipping programs. Contact your health plan for details. For additional information regarding reimbursement see here:

https://www.cms.gov/files/document/11022-faqs-otc-testing-guidance.pdf

No – health plans are not required to cover OTC at-home tests purchased prior to January 15, 2022. The guidance is effective January 15, 2022 and runs through the end of the COVID-19 Public Health Emergency.

https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx

No. The federal government's plan to mail OTC at-home COVID-19 tests is a separate program that will not involve your insurer. For more information on the program, visit https://www.covidtests.gov/.

From March 19, 2020 through July 22, 2021, Executive Order 2020-09 expanded the scenarios in which health insurance companies were required to cover telehealth services. DOI published Company Bulletin 2020-04 on March 25, 2020 to provide additional guidance on EO 2020-09. On July 22, 2021, Governor Pritzker signed PA 102-0104 into law. PA 102-0104 takes immediate effect and will supersede the telehealth benefit coverage requirements of EO 2020-09.

From March 19, 2020 through July 22, 2021, Executive Order 2020-09 was in effect and Company Bulletin 2020-04 provides guidance on the services required to be covered. On July 22, 2021, Governor Pritzker signed PA 102-0104 into law. Under PA 102-0104 an individual or group policy of health insurance coverage, other than a dental service plan, must provide coverage for telehealth services, and it must comply with the following requirements:

Insurers may not:

• Require that in-person contact occur between a health care provider and a patient;
• Require the health care provider to document a barrier to an in-person consultation for coverage of services to be provided through telehealth;
• Require the use of telehealth when the health care provider has determined that it is not appropriate

Under 215 ILCS 356z.22(c)(2), cost sharing for telehealth shall not exceed cost sharing required by the insurance carrier for the same services provided in person.

The telehealth mandate applies to fully insured individual or group health insurance coverage offered by an HMO, a PPO, a major medical plan that does not use a provider network, or a voluntary health services plan. The mandate also applies to a fully insured limited health service plan or fully insured dental or vision plan, except for a dental service plan. Other than dental, vision, and limited health service plans, excepted benefit policies are not subject to the telehealth mandate. For State, county, municipal, or school district employees, the same types of coverage are subject to the mandate as described above regardless of whether they are fully insured or self-funded. However, all self-funded plans of individual private employers and all Federal governmental plans are exempt from the mandate.

Under 215 ILCS 356z.22, telehealth services are defined as the delivery of covered health care services by way of interactive telecommunications systems. Interactive telecommunications systems include audio or video system permitting 2-way, live interactive communication between the patient and the provider. The EO relaxed the restrictions on services subject to the Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110) so that patients could use any non-public facing remote communications. This was based on federal guidance that would temporarily allow non-public facing remote communications for all health care services that could be conducted through telehealth. The EO still remains in effect to relax these restrictions. Once the EO is not in effect, the restrictions of the Mental Health and Developmental Disabilities Confidentiality Act will apply to related health care services. For services not subject to that statute, the U.S. Department of Health and Human Services – Office of Civil Rights will determine how long and under what conditions any non-public facing remote communications may be used. Their March 2020 notification indicates that their permissive stance will last as long as there is a “COVID-19 nationwide public health emergency,” but their guidance may be subject to change. See Notification of Enforcement Discretion for Telehealth | HHS.gov.

Yes. Plans may include a designated telehealth or virtual provider panel or tier. However, the plan may not exclusively limit or restrict the availability of telehealth benefits to enrollees to the designated panel or tier. Additionally, the plan may provide incentives for the use of the designated panel or tier by offering lower out-of-pocket expenses to enrollees when the designated panel or tier are utilized. Please note, telehealth benefits deemed clinically appropriate may be rendered by any provider as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 and the Mental Health and Developmental Disabilities Confidentiality Act.

Under PA 102-0104, “Health care professionals and facilities shall determine the appropriateness of specific sites, technology platforms, and technology vendors for a telehealth service, as long as delivered services adhere to all federal and State privacy, security, and confidentiality laws, rules, or regulations, including, but not limited to, the Health Insurance Portability and Accountability Act of 1996 and the Mental Health and Developmental Disabilities Confidentiality Act.” When the EO and the federal flexibilities eventually disappear, providers’ telehealth platform options will be limited by those statutes once again, but providers will not be required to use a particular platform proposed by a carrier. Nothing prohibits a provider and a carrier from agreeing to use a common platform, for example, as a component of a carrier’s designated telehealth panel. The Department does not have purview over how the costs of the telehealth platforms are allocated.

You are encouraged to make every possible effort to maintain coverage by making at least the minimum payment. If that is not possible, you should contact your agent or insurance company, as many companies are extending various offers to policyholders

Typically, property insurance does not have a grace period. However, the Department encourages you to contact your agent or insurance company regarding options if you are unable to pay your premium when due. Some companies are making arrangements with policyholders regarding premium payments.

The Department is strongly encouraging insurance companies to be as flexible as possible with consumers. Many companies have informed the Department that they are addressing consumer needs in various ways. Contact your agent or insurance company for more information.

You are encouraged to file a consumer assistance request with the Department. The most efficient way to do that is online at: https://mc.insurance.illinois.gov/messagecenter.nsf

Business interruption insurance is insurance providing lost income and extra expense coverage that businesses incur as a result of an interruption to their business operations. Business interruption insurance coverage found in most policies require that the interruption be a result of direct physical loss to the property and that the loss or damage must be a result of a covered peril. Insureds should review their policies for specific terms and conditions of their coverage.

Most business interruption insurance coverage contains a virus and bacteria exclusion that specifically excludes losses that result from any virus, bacterium, or other microorganism that induces or is capable of inducing physical distress, illness or diseases. Please refer to your policy for your specific coverage and consult your agent or insurer if you have questions.

It is possible to have business interruption coverage under another type of insurance policy. For example, there may be available coverage in policies that cover perils arising out of actions by civil authorities or interruption of your supply chain. You should review your policy and see if it is a covered cause of loss or if it is excluded.

Some policies may provide coverage for “civil authority”, which addresses the situation when government prohibits access to your business. If your policy requires a “covered cause of loss” to be the reason why the civil authority restricted access to your business, coverage will depend on whether the COVID-19 outbreak is deemed a covered cause of loss. Some business policies do not have this requirement. Please read your policy carefully.

No. You cannot purchase an insurance policy that would cover a loss that has already occurred. However, you may be able to purchase a business property policy that includes business interruption coverage for future losses. You should review the policy to determine the scope of the coverage provided and discuss any potential other stand-alone coverages that might be appropriate for future losses.

Business interruption insurance usually requires direct physical loss. Please refer to your policy for your specific coverage and consult your agent if you have questions.

The Small Business Administration (SBA) is offering small businesses impacted by COVID-19 up to $2 million in Economic Injury Disaster Loan Assistance (EIDL). Small businesses in Illinois are now eligible to apply for low interest U.S. Small Business Administration (SBA) Economic Injury Disaster Loans.

Under the EIDL program, the SBA makes loans available to small businesses and private non-profit organizations in designated areas of a state or territory to help alleviate economic injury caused by the COVID-19.

Small business owners can apply online, receive additional disaster assistance information and download applications.Applicants can call SBA's Customer Service Center at (800) 659-2955 or email disastercustomerservice@sba.gov disastercustomerservice@sba.gov for more information on SBA disaster assistance. For deaf or hearing-impaired individuals, call (800) 877-8339.

Completed applications should be mailed to U.S. Small Business Administration, Processing and Disbursement Center, 14925 Kingsport Road, Fort Worth, TX 76155.

If you need assistance, you can access information related to ILDCEO Grants here: Illinois Department of Commerce and Economic Opportunity

Your insurance agent should be able to answer questions regarding coverage and exclusions found in your policy. You may also want to visit your insurance company’s website for relevant information.

If you believe that your insurance provider is not honoring your policy, you can submit a complaint on our website, and our team will review it. An online complaint can be filed here: https://mc.insurance.illinois.gov/messagecenter.nsf

The Illinois Department of Insurance encourages you to file a complaint with the Department if you have any concerns that that your claim was improperly denied.

Please be assured that the Illinois Department of Insurance reviews all complaints involving denied claims very closely. However, as a regulatory agency, the Department does not have the authority to determine the liability or amount of a claim.

The Department cannot provide you legal advice or represent you in any legal action. If you wish to pursue this matter, you have the right to consult legal representation or seek recovery through the court system.

If you need assistance finding an attorney to represent you, the Illinois Attorney General, Consumer Protection Division maintains a list of legal aid providers and contact to the Illinois State Bar Association on their website. http://www.illinoisattorneygeneral.gov/consumers/index.html.

All temporary licenses that were set to expire during the Governor’s Disaster Proclamation were extended through July 24, 2021.

On July 25, 2021 all temporary licenses that are more than 90 days old will be canceled.

For producers who are set to renew during the Gubernatorial Disaster Proclamation, please understand that licensing requirements are NOT suspended at this time. Resident producers can still complete all CE requirements online, including the required 3-hour Ethics classroom course which can now be completed by webinar per P.A. 102-0135 , which permanently codified the webinar flexibility allowed by EO 2020-09.

Insurance exam testing is provided through Pearson Vue. For additional information please visit www.Pearsonvue.com.

Yes. P.A. 102-0135 allows the classroom part of the pre-licensing requirement to be provided via webinar or other distance learning

Yes. P.A. 102-0135 allows the required 3-hour ethics classroom course to be completed by webinar.

Currently, you have 90 days to retake and pass the failed part of the exam. If you do not pass within that 90-day period, then you must take both parts of the exam again.

NOTE:
Executive Order No. 2021-11 extended Executive Order 2020-29 through July 24, 2021.

Executive Order No. 2020-29 allowed all previously approved classroom courses delivered by an approved provider to be offered as a webinar or other appropriate distance learning without having to refile that course with the Department, extended temporary licenses past the 90 day expiration and extended the 90 day test requirement to pass both parts on the insurance exam.

As of July 25, 2021 the following extensions ceased:

• Temporary licenses that are older than 90 days will expire; and
• Applicants will no longer have an extension to the 90 day requirement to pass both parts on the insurance exam.

Resident producers can complete all CE requirements online, including the required 3-hour Ethics classroom course, which can now be completed by webinar per P.A. 102-0135, which permanently codified the webinar flexibility allowed by EO 2020-09.

Currently, the Department does issue a 90-day temporary license for applicants enrolled in a training course conducted on behalf of the appointing company. However, the extension past the 90 days will cease. Applicants are only allowed one temporary license in a lifetime.

It depends. Unless a travel insurance policy contains an exception applicable to COVID-19, a policy of travel insurance that covers the risks of sickness, accident, or death incident to travel presumptively would cover such risks relating to COVID 19 if experienced while travelling. The extent of coverage for health care services, including emergency transportation within a foreign country, as well as the costs of returning to the United States for further treatment, may depend on the terms of the policy so be sure to check with your insurance carrier.

If you purchased a Trip Cancelation or Trip Interruption policy after January 21 or 22, 2020, it is unlikely that you will be covered if your trip is canceled due a COVID 19 event—such as an coronavirus outbreak at your destination, or a quarantine that prevents you from traveling. Again, you should check with your insurance carrier for coverage and policy details.