Medicare and COVID-19: What You Need to Know

What first started as a cluster of pneumonia cases in China in December 2019 has been declared a pandemic by the World Health Organization (WHO). The highly-contagious infection has been identified as novel coronavirus (2019-nCoV), and has quickly spread to countries around the world.

Available data shows that the virus is more severe in seniors and in people with chronic medical conditions, especially if they are immunocompromised or have underlying conditions like diabetes, heart disease, or lung diseases like COPD. To get ahead of the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) has taken action to protect its beneficiaries. This is what you need to know.

Coronavirus Testing

If you have symptoms or are otherwise at risk for COVID-19 (e.g., you have been in contact with someone who has the disease), Medicare will cover your test free of charge. You will not have to pay a copay.

Keep in mind the test will not be performed unless it is ordered by a medical professional.

If you have symptoms and think you may be sick with COVID-19, you can use our printable Doctor Discussion Guide below to help prepare you for talking with your healthcare team about getting a diagnosis.

Coronavirus (COVID-19) Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Doctor Discussion Guide Old Man

Telehealth and Telemedicine

Getting sick during a pandemic can be anxiety-provoking. If you develop symptoms, you will want to be evaluated to assure you are not infected and to get the care you need when you need it. Some people may have chronic illnesses or transportation issues that make it difficult to get to an emergency room, urgent care clinic, or doctor's office. In addition, it could be risky to go into a waiting room full of people where you could spread the disease to others or vice versa.

If you suspect you have COVID-19, please call ahead before going to an emergency room or clinic. They will tell you what to do and where to go. It is important that they know you are coming to decrease the spread of infection.

This is where telehealth, also known as telemedicine, can help. These types of visits allow health professionals and patients to speak to each other in real-time using video conferencing. This can be done online or via mobile apps using HIPAA-compliant healthcare software.

Medicare Advantage plans were allowed to add telehealth as an optional supplemental benefit in 2019. Original Medicare also covers telehealth visits but limits who can use it. The service is available to people who live in qualifying rural areas and who are located at designated medical sites (i.e., visits are not covered from home), people who require stroke evaluations regardless of their location, and people who have end-stage renal disease and receive dialysis treatment at home.

The U.S. Centers for Medicare & Medicaid Services (CMS) has responded to the COVID-19 pandemic by expanding telehealth coverage for Medicare. During the national emergency, visits will be covered for all beneficiaries from any location but will still require you to pay a 20% coinsurance.

Even without this expanded coverage, though, a telehealth visit usually costs less than an in-office visit. The goal is to keep you at home whenever possible to decrease the risk of being exposed to COVID-19 in the community.

Hospitals and Skilled Nursing Facilities

People who live in rural areas may not live close to healthcare facilities. The Medicare Rural Hospital Flexibility Program helped to increase access to care by allowing certified critical access hospitals (CAHs) to open in those areas of need. These hospitals are smaller in scale than traditional hospitals but are required to have emergency rooms. A CAH is limited to having 25 inpatient beds and is not permitted to have hospital stays longer than 96 hours. In response to the COVID-19 pandemic, however, CMS has waived restrictions on CAHs so they can house more patients and lengthen their stays as needed.

Medicare will continue to pay for medically-necessary stays in a traditional hospital as well. That being the case, the two-midnight rule still applies. This means that you will be placed under observation (where Part B covers your stay) or admitted as an inpatient (where Part A covers your stay) based on how sick you are, the intensity services you receive, and how long you are expected to stay in the hospital.

People who require isolation may be considered appropriate for inpatient coverage, although this may be determined on a case-by-case basis.

Traditionally, Medicare requires you to have an inpatient hospital stay that lasts at least three days before it will cover a stay in a skilled nursing facility (SNF) or nursing home. Medicare Advantage plans have had the option to waive that rule but CMS is now allowing Original Medicare to waive that rule as well. If there are increases in COVID-19 cases, hospitals may reach peak capacity. In order to care for the sickest people, some patients may need to be diverted to other locations—including CAHs or SNFs—as they recover or are treated for less serious conditions.

Precautionary On-Site Restrictions

CMS has taken precautions to protect you when you stay in a skilled nursing facility. Fewer people will be allowed on the premises and there will be fewer interactions between the residents. That means there are restrictions on volunteers and non-essential employees, restrictions on visitors unless someone is at the end-of-life, and restrictions on group activities and communal dining. Social distancing can be difficult to achieve in such close quarters but every effort needs to be taken to decrease the risk of exposure to this contagious virus.

Clinical Outcomes

COVID-19 has taken its toll on the Medicare community. Between January and mid-May 2020, more than 325,000 Medicare beneficiaries were diagnosed with the infection. Black people were nearly four times more likely than whites to be infected (465 vs. 123 per 100,000). Hispanics and Asians were infected rates of 258 and 187 out of 100,000 respectively.

When it comes to pre-existing conditions, rates were higher for Medicare beneficiaries who had anemia, diabetes, hyperlipidemia, hypertension, or kidney disease. The highest rate (1,341 per 100,000) was reported for those who had end-stage renal disease (kidney disease requiring dialysis).

Of those infected, nearly 110,000 were hospitalized. Those hospitalizations have cost $1.9 billion for people on traditional Medicare or about $23,100 per patient. Unfortunately, as many as 28% of Medicare beneficiaries who were hospitalized with COVID-19 died.

A Word from Verywell

Seniors and people with chronic conditions are at greater risk for developing severe respiratory complications from COVID-19. With that in mind, CMS has taken action to increase Medicare coverage and improve access to services that can help diagnose and treat the condition.

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Article Sources
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  1. World Health Organization. WHO Director-General's opening remarks at the media briefing on COVID-19. March 11, 2020.

  2. Centers for Disease Control and Prevention. Are you at higher risk for severe illness?. Updated March 18, 2020.

  3. U.S. Centers for Medicare & Medicaid Services. Coronavirus Test.

  4. U.S. Centers for Medicare & Medicaid Services. Telehealth.

  5. U.S. Centers for Medicare & Medicaid Services. Critical Access Hospitals. Updated April 9, 2013.

  6. Centers for Medicare & Medicaid Services. CMS Announces New Measures to Protect Nursing Home Residents from COVID-19. March 13, 2020.

  7. Verma S. Medicare COVID-19 Data Release Blog. June 22, 2020.