Insurance Coverage and COVID-19

Although the Public Health Emergency (PHE) ended on May 11, 2023, COVID-19 vaccines continue to be distributed by the federal government and remain free. The transition of vaccine purchase and distribution to the traditional health care system is anticipated to take place in the second half of 2023.

After the transition to full commercialization, if you have Medicare, Medicaid, an ACA Marketplace plan, or private insurance the vaccine itself, will remain free for most covered individuals.

If you do not have insurance or have a high-deductible or catastrophic-only plan, vaccinations may still be available to you at no cost. On April, 18, 2023, the U.S. Department of Health and Human Services announced the “HHS Bridge Access Program For COVID-19 Vaccines and Treatments” for uninsured individuals.  Additionally, vaccine manufacturers may have patient assistance programs for uninsured or underinsured individuals. To learn more about the COVID-19 vaccine, please refer to the Illinois Department of Public Health (IDPH). You may wish to contact a nearby federally-qualified health center (FHQC), Rural Health Clinic, or other clinic. Information can be found at Find a Health Center (hrsa.gov).

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 currently not allowed to charge you the administration fee when you are getting your shot or to send you a bill for the fee afterwards. Medicare, Medicaid, and most private insurance plans are currently not allowed to leave you with the bill for any portion of the administration fee. However, after the transition to commercialization, you may be charged for vaccine administration if you utilize an out-of-network provider or pharmacy.

If you use  a short-term limited-duration insurance policy or an "excepted benefits" policy to cover your vaccination visit, the insurer may leave you with some of the bill for both the cost of the vaccination as well as 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.

If you need assistance locating an authorized vaccine provider you can visit the CDC’s COVID-19 vaccination websites at How Do I Find a COVID-19 Vaccine? | CDC and Vaccines.gov - Find COVID‑19 vaccine locations near you

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

Depending on the circumstances, the testing provider might bill you directly or they might bill your insurance carrier. If you have private insurance, including Medicare Advantage, you may be responsible for some cost-sharing for both the test and doctor’s visit. Some plans may continue to provide free diagnostic testing as part of your benefits and coverage. Contact your insurance carrier if you have questions about your coverage and possible cost-sharing

If you have insurance, the testing site may ask you for your insurance card and information and bill your insurance.   Persons with traditional Medicare will still pay nothing for PCR and antigen tests, and Medicaid beneficiaries will still qualify for free on-site COVID-19 testing until at least September 30, 2024. 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.

If your employer has a routine, mandatory COVID-19 testing program, state law prohibits an employer from requiring an employee to pay for the cost of medical examinations or records that the employer requires as a condition (or precondition) of employment. For more information, please refer to the Illinois Department of Labor (IDOI).

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 refer to IDPH.

During the Public Health Emergency (PHE), many COVID-19 medications and treatments (such as Paxlovid or monoclonal antibodies) were available to the general public for little-to-no-cost regardless of your insurance status. Once the PHE ends – and once the free federal supply of some medications and treatments run out – individuals with insurance may be responsible for some medication and treatment costs depending on the individual’s coverage. Please contact your plan to learn more about your options and coverage.

For Medicaid customers, COVID-19 treatments will continue to be covered without cost-sharing until at least September 30, 2024. Most uninsured persons will be required to pay some or all the cost of these medications and treatments but may qualify for discount or free treatment options. On April, 18, 2023, the U.S. Department of Health and Human Services announced the “HHS Bridge Access Program For COVID-19 Vaccines and Treatments” for uninsured individuals.

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 IDPH.  You can also visit the federal government’s COVID-19 website at COVID-19 | USAGov.

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. 

If you have private a private health insurance or Medicare Advantage plan, you may be responsible for the cost of at-home COVID-19 tests. Contact your insurance carrier to check for coverage details.

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.

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

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

Individuals with traditional Medicare will be responsible for the cost of OTC at-home tests. Individuals with Medicare Advantage plans are encouraged to contact their insurance carrier to check for coverage details. 

Medicaid and CHIP will continue to cover at home tests until at least September 30, 2024.

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

If you have questions about your coverage, the Department recommends you contact your health plan.

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/. 

It is not clear at this time if the federal government will continue to do so. Please refer to COVID.gov/testing for updates.

On July 22, 2021, Governor Pritzker signed P.A. 102-0104 into law. P.A. 102-0104 took immediate effect.

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. Once the Public Health Emergency (PHE) endshttps://www.illinois.gov/government/executive-orders/executive-order.executive-order-number-15.2021.htmlmany consumer-grade platforms such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Sype, or Zoom for Health will no longer be allowed for telehealth services. Health care providers currently using those platforms who wish to continue offering telehealth services after the public health emergency ends should seek out a platform that complies with HIPAA privacy standards. For more information about the temporary relaxation of HIPAA privacy standards for telehealth, visit the federal website  here.

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.

After the end of the Public Health Emergency (PHE) telehealth providers will still be able to prescribe most controlled substances without conducting an in-person examination of the patient or receiving a referral from another practitioner who has conducted an in-person examination. The Drug Enforcement Agency (DEA) has extended telehealth prescribing flexibilities for controlled substances and has clarified that if a telemedicine relationship was established during the PHE, the DEA will extend the in-person exam waiver for an additional 180 days. The Biden Administration announced on May 9, 2023, that telehealth prescription flexibilities for controlled substances will last until November 11, 2023, and is working towards a permanent telehealth rule. Coverage for the controlled substance, itself, will remain subject to the terms of your policy and any applicable State or federal mandates.

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.

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.

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.

For producers who are set to renew, 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.

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.

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.

Check with your insurance carrier for coverage and policy details.

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.