By Eagan Kemp, Melinda St. Louis, Taylor Lincoln & Mike Tanglis
Summary of Findings
The vast majority of the largest health insurers say they are offering at least some fee waivers for the treatment of COVID-19 patients, but these fee waivers contain significant restrictions and most are set to expire long before the pandemic can reasonably be expected to end.
Most of the fee waivers are set to expire soon. Of the 25 largest health insurers, 21 have announced that they are waiving all costs – such as deductibles and co-payments –for COVID-19 patients, at least for in-network care, and two are offering fee-waivers for some COVID treatment. But 15 of the 23 fee-waiver offers are set to expire by July 1, including 11 by June 1.
Few of the fee waivers appear to cover costs for out-of-network care. Only two of the 25 largest insurers affirmatively state that they will cover patients’ costs for care provided by both in-network and out-of-network providers. This distinction is important because many patients might not be able to obtain care from in-network practitioners due to the high rate of hospitalization in some locations.
Up to 60 percent of people in private insurance plans may not be covered by the fee-waivers because they are in self-insured plans. The fee waiver offers universally exclude those in self-insured plans unless the employers that underwrite the plans opt-in. About 60 percent of people who receive insurance through employers are in self-insured plans.
Some insurers are providing few, if any, expanded benefits for coronavirus treatment. Two large insurers – CareSource and WellCare – appear to be offering little beyond their normal coverage.
Descriptions of testing benefits need improvement. Although Congress has mandated free testing for COVID-19 with few restrictions, many of the large health insurers’ descriptions of testing benefits are unclear and/or appear to impose restrictions that the recent legislation did not call for.
Partly in response to government mandates, health care insurers have to varying degrees announced increased benefits for screening, testing and treatment of COVID-19, otherwise known as coronavirus.
To the extent that insurers are offering increased benefits voluntarily, they are likely seeking to earn good will. But the fine print attached to the increased benefits is apt to reinforce Americans’ perception that private insurers’ benefits are incredibly difficult to navigate and are riddled with financial hazards and pitfalls.
Aside from putting forth confusing descriptions of the COVID-19 benefits, many insurers simply are not doing their part to help their customers through this crisis. Early indications are that insurers are experiencing lower overall costs during the pandemic due to dramatic reductions in non-COVID health care services – such as elective surgeries – that are more than compensating for insurers’ payments for treatment of coronavirus patients. In a time of shared sacrifice, it would be absurd for health insurers to benefit financially from the greatest health emergency in a century.
Most of the large insurers are offering blanket waivers from deductibles, co-payments and other out-of-pocket costs for coronavirus patients, at least for in-network care. But some insurers have been much stingier in the enhanced benefits they are offering.
Insurers should guarantee free COVID-19 care and stipulate that this offer is retroactive to the beginning of the coronavirus emergency and will last throughout its duration. Employers that underwrite self-insured plans also are likely experiencing reduced health care costs and should ensure that their employees’ costs for coronavirus treatment are covered, as well. This is crucial because about 60 percent of Americans with private insurance are in self-insured plans.
While Americans would welcome blanket protection from costs for coronavirus treatment, this would only serve as a temporary solution to the broader problem that plagues American health care. The system is unfathomably complicated, ridiculously expensive to administer and rations care according to people’s ability to pay. This is not only morally bankrupt but, as the spread of coronavirus indicates, it is also dangerous from a public health standpoint because we are all affected by the community’s overall health and ability to obtain needed care.
The most sensible way to untangle the thicket of our health care system, protect Americans from crushing costs, and create a healthier and more productive society is to implement Medicare for All, under which patients would receive the care they need for free and providers would be compensated at a fair rate for services rendered.
Lawmakers and some insurers were right to move in the direction of free care for coronavirus, but stopping there would not make sense. There are many health conditions that, although less publicized than coronavirus, are even more deadly. If free care makes sense for COVID-19 patients, the same is true for those suffering from cancer, heart disease, complications at birth and myriad other conditions.
I. Offers of Free Treatment for COVID-19 Are Riddled With Loopholes
This report studies the statements on COVID-19 benefits offered by the 25 largest health insurers in the United States as listed by the National Association of Insurance Commissioners for 2018.
Most of the large insurers, but not all, say they are offering at least some increased benefits for COVID-19 treatment. But these expanded benefits, or fee waivers, include significant caveats. Most of the treatment waivers cover in-network care only and exclude members whose plans are self-insured unless their employers opt in. Most of the waivers have end dates that will arrive long before the end of the health emergency.
Further, the insurers’ descriptions of the fee waivers are often unclear and contain insufficient warnings about exceptions.
Most of the Treatment Waivers Apply to In-Network Care Only, Meaning Many COVID-19 Patients Could Face Huge Medical Bills
The offers of insurers that are waiving COVID-19 treatment costs break down into three categories: 1) costs are waived for both in-network and out-of-network treatment; 2) costs are waived for in-network treatment and out-of-network emergencies; and 3) costs are waived for in-network treatment only.
Very few insurers are offering waivers for both in-network and out-of-network treatment. Blue Cross Blue Shield of Massachusetts (BCBS of MA) appears to be an exception. According to its web site, BCBS of MA will cover the costs of: “counseling, supportive care, and treatment, including supportive care at doctor’s offices, urgent care centers and emergency departments,” as well as “inpatient care at both in- and out-of-network acute care facilities for our fully insured members.” Blue Cross Blue Shield of Michigan has taken a similar tack. “We want you to stay focused on getting better. If you need treatment for COVID-19 symptoms between now and June 30, 2020, we’ll take care of the cost. Treatment of symptoms can be on an inpatient or outpatient basis, from both in-network and out-of-network providers,” BCBS of Michigan says.
A few other insurers, such as Health Care Service Corporation (HCSC), will pay for COVID-19 treatment at “in-network facilities and treatment for out-of-network emergencies.”
The treatment cost waivers offered by most of the insurers fall into the third and least generous category: covering in-network treatment only. Receiving out-of-network treatment often results in a massive medical bill. The unprecedented circumstances surrounding COVID-19, with overflowing hospitals in some areas, undoubtedly have forced some patients to seek care from providers outside their network. Meanwhile, patients who visit in-network hospitals sometimes unwittingly receive care from out-of-network physicians serving those centers and, thus, find themselves liable for out-of-network costs through no fault of their own.
Members With Self-Insured Plans Could Face Costs Even if Their Insurer Is Waiving Fees
As noted previously, about 60 percent of Americans who receive health insurance through an employer are in plans that are self-insured, meaning that the insurer administers the benefits but the employer pays the claims.
The largest insurers have generally noted that fee waivers do not apply to those in self-insured plans unless the employer opts to offer the expanded benefits. This means that millions of Americans whose plans are administered by insurers that are ostensibly waiving fees for coronavirus treatment may nonetheless face substantial costs.
Insurers Need to Provide More Clarity on Exceptions to the COVID Fee Waivers
Many insurers’ references to potential liabilities for out-of-network care and people in self-insured plans express this information in technical terms that their customers would not necessarily understand.
CareFirst provides an exception. The company writes: “If you receive this care from an out-of-network provider, you will have coverage, but that provider may bill you for the balance where allowed.”
Most of the insurers that are offering only in-network waivers are less forthcoming about what happens if a member receives out-of-network care. For example, Cigna states that it is “waiving out-of-pocket costs for all COVID-19 treatment through May 31, 2020.” Cigna then says, “the company will reimburse health care providers at Cigna’s in-network rates or Medicare rates, as applicable.”
Cigna’s statement, which is similar to those of many insurers, likely means that patients will be liable for fees charged by out-of-network providers that are in excess of the in-network or Medicare payments they receive from Cigna. If this is the case, Cigna and the other insurers should say so very clearly.
The caveat offered by Independence Health Group is particularly cryptic. The company’s statements promising cost waivers includes a footnote far removed from the statement that reads, “for employers who are self-insured, coverages may vary. If you have coverage through your employer, please check with them about how these programs apply.”
Florida Blue’s statement includes the following headline: “Rest assured: the COVID-19 test and treatment are $0 cost share for our members” and does not warn of exceptions in the paragraphs that follow. In another location on its Web site, Florida Blue provides a similar promise, but with the caveat, in parentheses: “Florida Blue is also working with its self-funded ASO group employers to assist them in meeting the needs of their employees during the health crisis.” Separately, in a press release touting free care, Florida Blue wrote, “Florida Blue is also working with its self-funded ERISA employers to assist them in meeting the needs of their employees during the health crisis.”
Florida Blue’s statements are highly flawed. One outright fails to alert policy holders that the free care does not necessarily apply to them. Other Florida Blue statements on free care imply exceptions, but do not expressly state them. Saying that “Florida Blue is also working with” self-funded ASO groups and self-funded ERISA employers does not clearly indicate that members in these groups will not necessarily receive free care. Finally, terms such as “self-funded ASO groups” and “self-funded ERISA employers” are too technical for customers to be expected to understand.
While insurers may not be able to compel employers with self-insured plans to waive treatment costs for their employees, they should explicitly define what a self-insured plan is and provide better guidance on how members can figure out if their plan is self-insured and what benefits are being offered under it.
Some Insurers Are Providing Only Partial Care or No Expanded Benefits for Coronavirus Treatment
While most of the largest insurers are providing complete cost waivers for in-network care, some are offering only partial fee waivers or none at all.
WellCare, an insurer that provides Medicare, Medicare Advantage, Medicaid, and prescription drug plans, announced it would waive “cost-sharing for COVID-19 treatments in doctor’s [sic] offices or emergency rooms and services delivered via telehealth.” There is no mention of waiving any costs related to inpatient admissions. An extended hospital stay due to COVID-19, potentially involving time in the intensive care unit, could easily cost tens of thousands of dollars.
Independence Health Group
According to its web site, Independence Health Group “will waive members’ cost for in-network, acute inpatient treatment of COVID-19 received between March 30 and May 31, 2020.”  This offer does not appear to include costs for care that does not result in acute in-patient treatment.
There are other major exceptions to Independence’s offering. The Independence statement says, “cost sharing will continue to be applied to all post-acute care (e.g. skilled nursing, rehabilitation and long term acute care facilities), outpatient treatment, prescription drugs, ambulance transportation to a post-acute setting, and out of network care.”
On Emblem Health’s COVID-19 FAQ page, the company says, “all normal coverage restrictions and cost-sharing charges will apply for care or treatment, including inpatient hospital admissions.” This suggests that Emblem is not offering expanded benefits.
CareSource’s web page lists eight benefits and services available to its members related to COVID-19. While the list includes items like “no out-of-pocket costs” for testing, it makes no reference to any waivers related to treatment. When CareSource announced it was waiving the out-of-pocket-costs for testing for all members, the company put out a press release announcing the plan. In CareSource’s press releases dating back to early March, the company touts its donations of food and money to help alleviate effects of the pandemic, but no press release mentions enhanced treatment benefits.
The Waivers Include Arbitrary Timeframes
The cost waivers that 11 the large insurers are providing their members are set to end by June 1, while four more have an end date of June 30. Meanwhile, an internal Trump administration analysis concluded that deaths and new cases from coronavirus will be significantly higher in June than in May.
If deadlines are not extended, those treated on May 31 for COVID-19 may have all their costs covered, while a patient treated on June 2 could face financial ruin. Patients cannot control when they get sick, and it is logically inconsistent to deem expanded benefits as warranted on one date but not another. A fair policy would be to extend the expanded benefits for the duration of the health emergency and also to apply them retroactively to the beginning of coronavirus cases in the United States.
Proposed Model Language
Insurers appear to be saving more from reduced non-COVID-19 claims, particularly concerning elective procedures, than they are paying in COVID-19 claims. To the extent that this is true, insurers should fully cover COVID-19 care. The following language draws on the best of the insurers’ offers. We recommend that insurers adopt language like this and display it prominently on the front page of their web sites:
We are committed to ensuring that our members do not face hurdles to receiving the care they need for treatment of COVID-19. Our members will pay zero costs for coronavirus screenings and treatment from any in-network provider and from out-of-network providers if the member initially makes a good faith effort to seek in-network care. This fee waiver applies to doctors’ visits, emergency room care, inpatient care, post-acute care, and all other care relating to a COVID-19 diagnosis. Some of our members are in plans that are self-insured by their employers. This means that we administer claims but the employer pays the claims. We cannot mandate that employers offer enhanced benefits. We have established a phone number (xxx-xxx-xxxx) that members may call to determine whether they are in a self-insured plan, and, if so, learn the details of their benefits for care relating to COVID-19.
II. Some Insurers’ Promises of Free Testing Are Unclear or Appear to Conflict With Mandates in Law
The Families First Coronavirus Response Act, which became law on March 18, states that health insurers offering group or individual health insurance coverage “shall not impose any cost sharing” for FDA-approved tests to diagnose COVID-19 nor any costs for items and services related to a visit to a health care provider that results in such a test for the duration of the federal health emergency relating to the pandemic. The Coronavirus Aid, Relief, and Economic Security Act (CARES Act), which became law on March 27, broadened the universe of tests to be included in that mandate.
This language has been broadly interpreted to mean that Americans with insurance can consult with a doctor on the need for COVID-19 testing and receive a test without paying a penny – and for the most part the law does mean this. However, a nuance in the language did exempt short-term policies – otherwise known as junk policies – that do not meet the minimum requirements under the Affordable Care Act. The Trump administration permitted the sale of these policies in 2018 and estimates that 1.3 million people have them.
An additional exception to the free testing mandates in the recent bills to address COVID-19 is that they fail to prohibit providers from supplementing the payments they receive from insurers for testing-related care by seeking additional payments from patients. These bills, which would occur when a person visits an out-of-network provider, are known as “balance bills” or “surprise bills.” Another exception to mandated free testing is that the law does not stipulate that screenings for testing must be free if the screening does not result in an order for a test.
Many of the insurers’ COVID-related statements, which are ostensibly intended to provide clarity to their members, are less clear about the nature of COVID testing benefits than the language in the legislation. In some cases, the insurers’ statements of testing-related benefits appear less sweeping than Congress required.
Some of the insurers’ statements only promise to cover testing-related costs through certain dates. Other statements suggest a more restrictive universe of covered tests than the legislation calls for. Meanwhile, most of do not clearly warn members that they might be subject to costs if they see out-of-network providers.
The best remedy would be for insurers to interpret Congress’s mandate broadly and to articulate prominently on their web sites in clear, unambiguous language that they offer free screening visits and free testing.
Restrictions on Dates of Free Testing Benefits
President Trump declared a national emergency relating to COVID-19 on March 13. The subsequent laws passed by Congress call for the free testing benefit to last throughout the national emergency.
But some insurers’ representations on their web sites indicate end dates for the offers. For example, Florida Blue writes, “Through June 1, the test is $0 for all members, and we are waiving the cost share for all covered services for the treatment of those with a positive COVID-19 diagnosis.”
Horizon Blue, in an update posted on April 20, wrote, “through June 30, 2020, all fully insured members, […] will not pay any cost share amounts (copay, coinsurance, deductibles) for covered services related to the testing, diagnosis and treatment of COVID-19.”
Cigna states that it is waiving out of pocket costs for “coronavirus diagnostic visits” through May 31, 2020, and waiving out-of-pocket costs for coronavirus testing (no end date listed). To the extent that “diagnostic visits” regards consultations leading to testing, however, the May 31 end date conflicts with the law.
Highmark wrote of its plans that “most plans will cover coronavirus testing and in-network hospital care.” But it includes the caveat: “*Exclusions may apply. This waiver continues through May 31, 2020.” In response to an inquiry from Public Citizen a Highmark spokesman wrote, “You have discovered an error on our website […] For Highmark members, COVID-19 testing is covered at 100 percent during the duration of the pandemic.”
CIGNA wrote in a statement issued on March 30 that summarized its previous announcements that it was “waiving cost-sharing for the COVID-19 diagnostic test when recommended by a health care professional” through May 31. 
At Least One Insurer’s Statement Conditioned Free Testing on a Patient Being Admitted to a Hospital
Highmark’s web site states under a heading on testing benefits “*This includes testing when recommended by a medical professional and care once you are admitted. While this coverage applies to most Highmark members, every plan is a little different.” In fact, the legislation does not indicate the testing benefit requires admission to a hospital and – with the exception of short-term plans – the mandate does not differentiate between types of plans.
Some Insurers Have Said That Free Testing Is Contingent on Patients Displaying COVID Symptoms
In at least one case, an insurer appeared to condition its provision of free testing on the member exhibiting symptoms of coronavirus.
Horizon BCBS of New Jersey asked in its Q & A coronavirus page, “Will Horizon BCBSNJ cover testing of asymptomatic members who have traveled or were in areas of possible exposure?” The company did not explicitly answer its own question, but it did suggest that it would not pay for tests for those who did not have symptoms. Horizon wrote in response to its question: “Testing asymptomatic individuals is not medically indicated and against the current advice of the CDC and World Health Organization. CDC recommends voluntary home quarantine for those who have traveled to/from countries where COVID-19 has spread or who have been exposed to individuals with the virus.”
While it is true that the CDC generally does not recommend prioritizing testing for asymptomatic people – presumably due to the shortage of tests and related resources – the legislation mandating free tests does not indicate that exhibiting coronavirus symptoms is necessary to qualify for this benefit. Many public health professionals have called for surveillance testing of asymptomatic individuals to prevent community spread of the illness once the current lockdown ends.
Most Insurers Fail to Warn Their Customers About Potential Surprise Bills
“Surprise bills,” otherwise known as “balance bills,” can occur when a patient receives care from an out-of-network provider and the insurer does not pay the entirety of the provider’s bill. The provider may then send the patient a bill for the balance due. Surprise bills can be astronomical.
The legislation lays out procedures to determine costs for COVID-19 tests but does not set out a pricing system for related doctors’ visits. Analysts have noted that this shortcoming presents the possibility of out-of-network physicians saddling their patients with surprise bills.
CareFirst advises its members that there will be no costs for testing and treatment of COVID-19 with the exception that, “If you receive this care from an out-of-network provider, you will have coverage, but that provider may bill you for the balance where allowed.” This disclaimer presumably would apply to screening visits to determine whether a COVID-19 test is needed, as well as to other doctors’ visits. Other large insurers did not generally include such warnings on their COVID-19 pages discussing free testing benefits. To the extent that those insurers are not offering to pay surprise bills, they should explain the risk to their members clearly.
Patients may receive some protection from balance bills due to conditions laid out by the U.S. Department of Health of Human Services. In guidance pertaining to money the federal government is offering health care providers to treat uninsured Americans, HHS wrote, “As a condition” of accepting such money “providers are obligated to abstain from ‘balance billing’ any patient for COVID-related treatment.”
At Least One Insurers Says Its Free-Testing Benefit Is Limited by the Location at Which Tests Are Received
Independence Health Group wrote, “Independence Blue Cross (Independence) will cover and reimburse member cost-sharing (such as co-pays, deductibles, and coinsurance) for the COVID-19 test and the administration of the test when performed at an in-network physician’s office, urgent care center, by a home health agency, or an emergency room.”
This list could confuse patients because many tests are being performed at ad hoc centers, such as football fields and parking lots. The federal government’s guidance on the coronavirus legislation explains that the testing “must be covered when furnished in non-traditional settings, as well as when provided in traditional settings.”
Meanwhile, Health Net states that “Medically necessary COVID-19 diagnostic testing and/or medical screening services and the associated physician’s visit will be covered when ordered, referred and/or performed in the following In-Network locations …” The law does not distinguish between in-network and out-of-network in its mandate for free testing, although it does exempt insurers from paying out-of-network rates for screening.
Proposed Policy Model Language
To better serve their members, insurers should prominently display on the front page of their web sites that costs for coronavirus testing and related screening are waived retroactive to the onset of testing for coronavirus and throughout the duration of the health emergency. The benefit should be interpreted broadly to include all screenings, especially because the criteria at present to be eligible for a test are ridiculously narrow. A model policy and statement that incorporates the best of what insurers have written would look something like this:
For the duration of the coronavirus national emergency, members will not be charged for screening for COVID-19 conducted by in-network or out-of-network providers, as long as the member makes a good faith effort to see an in-network provider. Members will not be charged for COVID-19 tests received from a federal- or state-approved testing center. This applies to all members, regardless of plan. This benefit is retroactive to the beginning of 2020.
AHIP, the trade association of the health insurance industry, has created a web site that summarizes benefits being offered by insurers for COVID-19 treatment. To an extent, this web site provides a service to the public. Perhaps inadvertently, however, AHIP’s round up offers a jarring reminder of how confusing health care benefits are. This reminder is especially poignant given that these explanations of benefits are being issued at a time when insurers are being uncharacteristically generous.
Insurers should simply offer free coronavirus treatment to their members for the duration of the pandemic. AHIP could assist in this process by offering model language to its members and recommending that they display this information prominently on the front pages of their web sites.
But this would only be a band-aid. Our health care system has lost its way. Its ends are geared toward profit, not care. Medicare has served its population much more efficiently than have private insurers. The current pandemic, and the insurers’ byzantine descriptions of their benefits, underscores the wisdom of improving Medicare and expanding it to the entire population.
Under Medicare for All, nobody would have to worry about falling through the cracks of a broken health care system and facing financial ruin. In no other comparably wealthy country do people face the same difficulties to qualify for the care they need. It’s time to move beyond wasteful, profit-driven health care system to one that would guarantee health care for everyone who needs it, regardless of ability to pay.
 U.S. health insurers benefit as elective care cuts offset coronavirus costs, Reuters (April 27, 2020), https://www.reuters.com/article/us-health-coronavirus-usa-healthinsuranc/us-health-insurers-benefit-as-elective-care-cuts-offset-coronavirus-costs-idUSKCN2291DY.
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 Health Care Service Corporation (HCSC) statement (April 2, 2020), http://www.hcsc.com/newsroom/news-releases/2020/hcsc-waives-member-cost-sharing-covid-19.
 CareFirst member updates (viewed on May 5, 2020), https://individual.carefirst.com/individuals-families/about-us/coronavirus-member-benefit-updates.page#tab=main&accordion=for-members-enrolled-in-a-carefirst-medicaid-plan-how-is-testing-and-treatment-being-covered-by-medicaid.
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 A separate Florida Blue COVID-19 web page (viewed on May 5, 2020), https://www.floridablue.com/covid19?utm_source=FBPAGE&utm_medium=Florida+Blue&utm_campaign=coronavirus.
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 WellCare COVID-19 web page (viewed on May 5, 2020), https://www.wellcare.com/en/Georgia/Providers/Bulletins/coronavirus-Extra-Steps-CARE
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 H.R.6201 – Families First Coronavirus Response Act, https://www.congress.gov/bill/116th-congress/house-bill/6201/text.
 Coronavirus Aid, Relief, and Economic Security Act (CARES Act), https://www.congress.gov/bill/116th-congress/house-bill/748/text.
 The law required free testing for individual plans. Federal law excludes short-term plans from those defined as individual plans. https://www.law.cornell.edu/uscode/text/42/300gg-91.
 Karen Pollitz, Private Health Coverage of COVID-19: Key Facts and Issues, KFF (March 18, 2020), https://www.kff.org/private-insurance/issue-brief/private-health-coverage-of-covid-19-key-facts-and-issues/.
 Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak, President Trump (March 13, 2020), https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/.
 Cigna coronavirus information (viewed on May 5, 2020), https://www.cigna.com/coronavirus/individuals-and-families.
 Highmark communication office e-mail to Public Citizen (May 1, 2020).
 Cigna press release (March 30, 2020), https://www.cigna.com/newsroom/news-releases/2020/cigna-waives-customer-cost-sharing-for-covid-19-treatment-and-deploys-clinical-teams-to-increase-virtual-care-capacity.
 CareFirst benefits update page (viewed on May 6, 2020, https://individual.carefirst.com/individuals-families/about-us/coronavirus-member-benefit-updates.page.
 Note on CARES Act, U.S. Department of Health and Human Services (page last reviewed by HHS on May 4, 2020), https://www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html.
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