If you’ve been exposed or have symptoms of COVID-19 and want to be tested, or are scheduling your COVID-19 vaccination, there are some things you should know beforehand with respect to your insurance coverage.
COVID-19 Testing and Your Coverage
Before you schedule your COVID-19 test, it is important to figure out what type of health care coverage you have. The laws and regulations impact your coverage in different ways depending on what type of coverage you have.
If you have symptoms or have been recently exposed and need to be tested and are:
- Covered by Medicare or Medicare Advantage: Medicare covers the lab tests for COVID-19 with no out-of-pocket costs and the deductible does not apply when the test is ordered by your doctor or other health care provider.
- Covered by Medical Assistance or CHIP: All lab tests, including tests for COVID-19, are covered without copayments or prior authorization.
- Covered directly through an insurance company, the health insurance marketplace, or through your employer (including through COBRA): A test may be covered if your attending physician evaluates your situation and deems a test is necessary.
- Covered through the Pennsylvania Employee Benefit Trust Fund (PEBTF): PEBTF/Retired Employees Health Program (REHP) medical plans will waive all deductibles, coinsurance and copays for diagnostic testing and in-network inpatient hospital care, emergency room or urgent care for COVID-19.
You’ll want to contact your insurance company to make sure that the testing lab is in-network.
If you’ve had no symptoms or recent exposure and are:
- Covered by Medicare and Medicare Advantage: If a test is recommended by an attending physician, the Families First Coronavirus Response Act requires coverage for the order of and administration of the test with no cost-sharing and no prior authorization.
- Covered by Medical Assistance or CHIP: An attending physician must write in an order for the test and then the Families First Coronavirus Response Act requires coverage for the order of and administration of the test with no cost-sharing and no prior authorization.
- Covered directly from an insurance company, the health insurance marketplace, or through your employer (including through COBRA): Check with your insurance company.
- Covered through the Pennsylvania Employee Benefit Trust Fund (PEBTF): Tests must be covered when there has been known or recent exposure to COVID-19 and it has been determined to be medically necessary by an attending physician.
COVID-19 Vaccine and Your Insurance
For all of the following coverage types, you will not have to pay anything for the vaccine, including a copay, coinsurance, or deductible, regardless of whether the provider is in-network or out-of-network:
- The major-medical health insurance market (individual market health insurance)
- Insurance through your employer (including through COBRA)
- Medicare and Medicare Advantage
- Medical Assistance through fee-for-service and Managed Care Organizations (MCOs)
- Children’s Health Insurance Program (CHIP)
- Pennsylvania Employees Benefit Trust Fund (PEBTF)
If you have no insurance, you should still be able to get the vaccine at no charge. It is best to call your primary physician prior to your vaccine appointment to verify that there will be no charge.