In the midst of the ongoing COVID 19 outbreak, the Illinois Department of Insurance (Department) is issuing a consumer FAQ recognizing the critical role that health insurance coverage plays in the public’s ability to access health care services.
This consumer FAQ does not apply to excepted benefit policies or short-term, limited-duration health insurance coverage.
1. How much will this vaccine cost me? Is it covered by my insurance?
There is no cost for the vaccine, itself. 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 not allowed to charge you the administration fee when you are getting your shot or to send you a bill for the fee afterwards. Also, Medicare, Medicaid, and most types of private insurance are not allowed to bill you for any portion of the administration fee in the form of a copay, coinsurance, or deductible.
However, if you use a grandfathered health plan, a short-term limited-duration insurance policy, or an "excepted benefits" policy to cover your vaccination visit, then the insurer may be able to bill you for 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. Regardless, no one can be denied a vaccine if they are unable to pay a vaccine administration fee.
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.
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2. Who pays for COVID 19 diagnostic testing if needed?
Depending on the circumstances, the testing provider might bill you directly or they might bill your insurance carrier. Regardless of who receives the bill, your insurance carrier is required by law to cover the full cost of your test and its administration as long as you received the test based on an individualized clinical assessment from a licensed or authorized health care provider. Contact your insurance carrier if you have questions about your coverage.
The testing site should not ask you for payment at the time of the test. If you have insurance, the testing site may ask for that information and bill your insurance. The Families First Coronavirus Response Act generally prohibits private health insurance coverage or group health plans from imposing cost-sharing on both the test itself and the health care provider’s administration of the test, as long as the purpose of the testing is for your individualized diagnosis or treatment of COVID-19. Additionally, health care providers who have received federal funds from the Provider Relief Fund are contractually prohibited from balance billing you for the test or its administration, even if they are out-of-network for your insurance plan. However, health insurance plans are not generally required to provide coverage of COVID-19 testing for public surveillance or employment purposes. 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.
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.
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.
3. Will I be subject to higher cost-sharing if I unintentionally receive care from out-of-network specialists in an in-network hospital?
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.
4. What if I have health concerns that require emergency medical services?
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.
5. Should I fill or refill my current prescription drugs in anticipation of an emergency?
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.
6 Can my insurance carrier cancel or refuse to renew my insurance policy if I am diagnosed with COVID 19 or a preexisting respiratory illness?
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.
7. Where can I find more information about COVID 19?
View up to date information on how Illinois is handling COVID 19 from the Illinois Department of Public Health
8. Is there a number to call for health insurance and HMO inquiries?
Yes. If you have questions regarding health insurance and HMO inquiries, please call the Illinois Department of Insurance at (877) 527-9431.
9. Is there a number to call for Medicare Beneficiaries and Caregiver Inquiries?
Yes. If you have questions regarding Medicare beneficiaries and caregiver inquiries, please call CMS at (800) 548-9034.
