Wash your hands and check your health care benefits to see what’s covered!
Because of the COVID-19 coronavirus pandemic we’ve learned a new term — social distancing — and
relearned the importance of thoroughly washing our hands.
We’ve also learned the importance of understanding what tests, procedures and care are covered by
our health insurance. In the beginning weeks of the pandemic, insurance carriers’ call centers were
inundated by calls from plan members wanting to know if their coverage would pay for the cost of a
coronavirus test. Complicating the matter is that copays and deductibles vary depending on the type of plan. According to the Kaiser Family Foundation, the average deductible for single coverage was $1,655 in 2019.
During the crisis, many insurance companies have covered the costs of the tests, and the Trump
administration designated the COVID-19 test as an essential health benefit. This meant that Medicaid
and Medicare plans covered the cost of the screening. A few states, including New York and
Washington, and some health insurers, waived copayments or deductibles for patients who needed to
be tested for the virus. Some carriers waived the pre-authorization requirement for testing or for
medically necessary covered services for members diagnosed with COVID-19.
For most individuals with insurance, treatment costs for the coronavirus have been the same as with
the flu or pneumonia. Covered members must pay a co-pay for visiting the doctor, and if they are
treated at a hospital, they must pay their deductible.
Where to Go to Learn About Your Benefits
One important lesson we can take away from this unprecedented experience is that you shouldn’t
wait until you’re ill or a pandemic strikes to learn what type of health care benefits you have. You also
don’t have to just rely on calling your health plan’s customer service line — which can unfortunately be a long wait during a time of crisis.
Remember, the more you know about what type of coverage you have and what it will cost, the
quicker you can respond. Here are a few ways you can find out exactly what will be covered before — or if — you and your family become ill:
Member Welcome Kit
One of your most valuable sources of information is the welcome kit that is mailed to you when you
enroll in a plan. Most welcome kits feature:
• ID Cards to demonstrate you have coverage
• Benefit information showing what services are covered
• Details about value-added benefits, such as wellness services or discounts
• Information on how to file a claim
• Pharmacy information
• The insurance company’s phone numbers and emails
• Directions on choosing a provider in-network if you have a PPO plan.
ID Card
Your ID card is not only your proof of insurance, it also gives providers information on what you will
owe as a copay and where the provider should submit a claim.
If you didn’t receive a card or have lost your card, call your insurer — their phone number should be
on their website.
Login/Website
Insurance carriers provide login, or self-service sites for members to find out more information about
their health benefit plans. Not only do these sites usually contain information about benefits, but they
also may feature plan documents, claim payments and coverage dates. Some sites allow members to
make changes in coverage and update address changes.
Summary Plan Description
Plan administrators must offer covered members a Summary of Plan Document (SPD) which tells
participants:
• What the plan provides
• How it operates
• When an employee can begin to participate in the plan
• How to file a claim for benefits.
If a plan is changed, participants must be informed, either through a revised summary plan
description, or in a separate document, called a summary of material modifications, which must be
provided free of charge.
If you can’t find a copy of your SPD and want one, you should make your request to the insurance
company in writing.
Explanation of Benefits
After a medical provider submits a claim to your insurance company for services rendered, the
insurance company will pay the claim and send you an Explanation of Benefits (EOB). This is a statement about your medical insurance claim. The insurance company usually mails the EOB to you, but it may also post it in the login or self-service website. The EOB looks like a medical bill — but it isn’t. It explains what portion of the bill the insurance company paid to the health care provider and what portion of the payment, if any, is your responsibility. You should pay any portion of the medical expense not covered by the insurance company, such as a deductible or a co-pay, directly to the provider.