Does Medicare Cover Long COVID?

Medicare covers the symptoms of long COVID, but your access to specialists may vary.
Kate Ashford, CSA®
By Kate Ashford, CSA® 
Edited by Holly Carey

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Nearly 1 in 4 adults age 65 and over who have had COVID-19 have experienced long COVID symptoms afterward, according to data from the U.S. Census Bureau.

Long COVID includes a wide list of lingering health problems that may occur at least four weeks after being infected with COVID-19, according to the Centers for Disease Control and Prevention. These symptoms may include fatigue, shortness of breath, cough, chest pain, trouble concentrating, headache, sleep issues, changes in smell or taste, depression or anxiety, and joint pain.

“The big challenge of long COVID is that it is so new,” says Katy Votava, who holds a doctorate in health economics and nursing and is president and founder of Goodcare, a consulting firm focused on the economics of Medicare. “There really aren’t that many specialists that deal with it.”

Medicare covers treatment for long COVID, including pulmonary rehabilitation services related to symptoms after a COVID-19 infection. The ability to see a doctor who specializes in long COVID treatment, however, may depend on where you live and whether you have Original Medicare or Medicare Advantage.

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Original Medicare vs. Medicare Advantage long COVID coverage

Both Original Medicare and Medicare Advantage cover treatment for COVID-19 as well as treatment for the symptoms related to long COVID. This includes, starting in 2022, coverage for pulmonary rehabilitation for people who had (or thought they had) COVID and who continued to have symptoms afterward.

If you have Original Medicare, you can see any specialist anywhere in the country who accepts Medicare coverage. This can be important if you’d like to consult a long COVID doctor or clinic that isn’t nearby.

On the flip side, Medicare Advantage, which is sold by private health insurance companies, usually requires members to get their care from providers and facilities within a network, which may be restricted to a geographic area.

“If you have one of the HMO [Medicare] Advantage plans, I’ve seen that to be more of an issue, where you have to get a referral from your primary doctor to see an in-network specialist,” says Garrett Ball, owner of Secure Medicare Solutions, an independent Medicare insurance agency. “But I think, in just the last six to 12 months, there’s probably been more access to doctors that are treating long COVID.”

For this reason, it’s important to check a Medicare Advantage plan’s network before you sign up so you can make sure your doctors — and any specialists you want to see — are included.

“A lot of this is constrained by where you live around the country,” says Sean Creighton, managing director at health care consultancy Avalere. If you’re in a large urban area, he says, you’re more likely to find a specialist, no matter which version of Medicare you have.

What if a long COVID specialist is out-of-network?

If you have a Medicare Advantage plan and there isn’t a long COVID specialist in-network, you have options. If you have a plan that allows you to see out-of-network providers, such as a PPO plan, you may be able to see a specialist who isn’t in-network and pay more out of pocket. If you have an HMO plan that doesn’t allow you to seek care out-of-network, you may be able to request a prior authorization or gap exception from your insurer to have the medical provider billed at in-network rates.

Take note: This is a high bar to clear because both your plan and the provider must agree to the arrangement, and it may be hard to find a medical provider who is inclined to negotiate. “The reason for that is probably cost,” said Diane Omdahl, president and co-founder of 65 Incorporated, which offers guidance on Medicare, in an email. “The plan has no control over out-of-network charges, and the provider won’t accept the plan’s amount.”

The process may vary by insurance company, so contact your plan's customer service to understand the best way to request that an out-of-network provider be accepted as in-network.

“That is certainly not always successful, but I have heard of instances where they are able to successfully appeal it and get a provider treated as in-network,” Ball says. “What I generally hear is that you have to have some documentation to prove that that’s your diagnosis, but also there are no doctors within a reasonable distance that are treating [long COVID] that are in-network.”

In the end, it may be easier to switch to a plan that includes that doctor in-network, enroll in a PPO plan that allows you to go out-of-network, or return to Original Medicare. You can change coverage during Medicare’s fall open enrollment period from Oct. 15 to Dec. 7 or — if you have a Medicare Advantage plan — during Medicare Advantage open enrollment from Jan. 1 to March 31. If there’s a 5-star Medicare Advantage plan in your area that’s better suited to your needs, you can switch to that plan once between Dec. 8 and Nov. 30 of the following year.

How does Medigap fit in?

If someone with long COVID is signing up for Medicare for the first time, Ball typically suggests they consider Original Medicare with a Medicare Supplement Insurance, or Medigap, plan. “It is market specific,” Ball says. “You still have to weigh the premiums versus the benefits of different types of plans.”

If you know you’re going to see a doctor frequently, Original Medicare with Medigap can limit your out-of-pocket costs. Because Medigap covers many of the costs of using Medicare, health care expenditures are predictable — you pay your premiums, and most copays and coinsurances are covered depending on the plan you choose.

And if you have health issues, it also may be difficult to get an affordable Medigap policy after the first six-month Medigap open enrollment period, which starts when you’re 65 or older and signed up for Medicare Part B. That said, Ball hasn’t seen any significant changes in Medigap underwriting to suggest that Medigap companies aren’t approving people with long COVID for policies.

“There may be conversations in underwriting departments about the cost of treating someone with long COVID being higher and maybe not being willing to take on that risk,” Ball says. “But I haven't personally had that come up. I haven’t had an application declined due to long COVID.”

This article was written with the support of a journalism fellowship from the Gerontological Society of America, the Journalists Network on Generations and the Silver Century Foundation.

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