1. Aetna Medicare Advantage Copays
2. Is Aetna Waiving Copays For Telehealth Visits
3. Aetna Copay Information
4. What Insurances Are Waiving Copays

Several private Medicare plan providers, including Cigna, Humana and Aetna, are waiving certain cost-sharing requirements for beneficiaries receiving treatment for COVID-19. Published April 2, 2020 Follow our Medicare Coronavirus News page for related information on coronavirus (COVID-19) and its impact on Medicare beneficiaries. CVS Health says it will waive cost-sharing and co-pays for Aetna’s commercial policyholders who are admitted to a hospital for treatment related to the coronavirus (COVID-19). The company said the. Aetna, the insurance company owned by CVS Health, said Wednesday morning that patients covered by its commercial insurance plans won’t be charged deductibles, copays or coinsurance for inpatient.

By waiving the copay and deductible obligations, Aetna members can obtain services at the Surgery Center for approximately the same rate as they would pay at an in-network surgery center. Aetna Extends COVID Cost Sharing Waivers until December 31, 2020 Aetna is reimbursing telemedicine at the same rate as an in-person visit (except for some telephone-only visits in commercial plans). For Medicare Advantage and Commercial plan members, cost-sharing is waived through the end of the year in these situations.

Published April 2, 2020

Follow our Medicare Coronavirus News page for related information on coronavirus (COVID-19) and its impact on Medicare beneficiaries.

The Centers for Medicare & Medicaid Services (CMS) mandated in early March that all testing for COVID-19 be covered in full by Medicare and private Medicare insurance carriers. A COVID-19 vaccine will also be covered if and when one becomes available.

Now, some private insurance carriers are going a step further by eliminating cost-sharing for COVID-19 treatment protocols as well.

Aetna Medicare Advantage Copays

Cigna, Humana and Aetna have each taken measures to reduce out-of-pocket spending for their Medicare plan members who undergo treatment for the disease. These out-of-pocket costs can include plan deductibles, coinsurance and copayments.

COVID-19 treatment can potentially include inpatient hospital stays, doctor’s office appointments, inpatient skilled nursing facility stays, home health visits and emergency ambulance transportation.

These services can typically come with costs such as copays and deductibles.

With waived coinsurance and deductibles for COVID-19 treatment, savings can add up

Cigna and Humana both waived COVID-19-related cost-sharing for their Medicare Advantage (Medicare Part C) plans.

Medicare Advantage plans cover the same inpatient and outpatient services and items that are covered by Original Medicare (Medicare Part A and Part B).

While Original Medicare is provided by the federal government, private insurance companies administer Medicare Advantage plans.

Some of the out-of-pocket costs that a beneficiary who has Original Medicare may face if they receive covered COVID-19 treatment include:

• Beneficiaries who have Original Medicare and who receive inpatient hospital treatment for COVID-19 will typically have to pay the 2020 Medicare Part A deductible of $1,408 for each benefit period that they receive inpatient care.
  There are also Part A daily coinsurance costs for lengthy hospital stays that last longer than 60 days.
  
• Beneficiaries who have Original Medicare and who receive outpatient care must pay the 2020 Part B deductible of $198 per year before Medicare covers the costs of their outpatient care.
  After meeting the Part B deductible, beneficiaries typically pay a 20 percent coinsurance or copay for covered services and items.

For members of Medicare Advantage plans from Cigna and Humana, however, those costs will be waived for covered COVID-19 treatment.

“Our customers with COVID-19 should focus on fighting this virus and preventing its spread,” David M. Cordani, President and CEO of Cigna¹

“While our customers focus on regaining their health, we have their backs,” David Cordani, President and CEO of Cigna, said in a statement.

Cigna’s cost-sharing waiver expires May 31, 2020.

“We know we’re uniquely positioned to help our members during this unprecedented health crisis,” said Bruce Broussard, President and CEO of Humana. “It’s why we’re taking this significant action to help ease the burden on seniors and others who are struggling right now.”²

Humana’s waivers includes costs related to COVID-19 treatment by both in-network and out-of-network facilities or physicians.

Humana’s cost sharing waivers currently have no end date, as the company plans to readdress the situation as needed.

Aetna, a CVS Health company, is also dismissing COVID-19-related inpatient cost-sharing for its members.

“The additional steps we’re announcing today are consistent with our commitment to delivering timely and seamless access to care as we navigate the spread of COVID-19,” said Karen S. Lynch, president of Aetna Business Unit. “We are doing everything we can to make sure our members have simple and affordable access to the treatment they need as we face the pandemic together.”³

Is Aetna Waiving Copays For Telehealth Visits

Aetna’s cost-sharing waiver for inpatient admissions to any in-network facility for treatment of COVID-19 is currently in effect until June 1, 2020.

The waiver of coinsurance and deductibles owed by patients treated by physicians and other health care providers has come under increased scrutiny recently. Although there are no clear legal prohibitions, commercial health insurers have aggressively pursued out-of-network providers who fail to collect or waive amounts owed by their insureds under different statutory regulations.

There have also been several recent settlements by health care providers resolving allegations of violating the False Claims Act for routinely waiving coinsurance amounts for Medicare beneficiaries.

Fraudulent Billing Alleged

In a recent case, Aetna sued Foundation Surgery Affiliates (FSM) and Foundation Surgery Management (FSM) for providing financial incentives, or kickbacks, to doctors to refer patients to Huntingdon Valley Surgery Center (Surgery Center) and for engaging in fraudulent billing practices. A federal appellate court in Pennsylvania agreed with a lower court’s ruling that the defendants cannot be liable under the state’s anti-kickback law because they are not licensed health care providers; however, the court also concluded that there was a genuine dispute of material fact as to whether it was fraudulent for the defendants to bill Aetna without disclosing the fact they had waived the patient’s copay and deductible obligations.

The Surgery Center is not a contracted network provider with Aetna. By waiving the copay and deductible obligations, Aetna members can obtain services at the Surgery Center for approximately the same rate as they would pay at an in-network surgery center.

According to the court, the Surgery Center’s obligation to disclose the routine waiver of a patient’s obligations would arise from the language of the billing forms it submits to Aetna or any contractual agreements with Aetna that require such disclosure. The court found that the billing form asks a provider to list the “total charges” and does not specify whether that term refers to the list prices or to the amounts the provider actually expects to receive.

The court also found that the Surgery Center’s rental network contracts (Beech Street and MultiPlan) through which its claims are processed did not clarify what information is required to be disclosed on the billing form. The court concluded that a lower district court erred in ruling that the Surgery Center’s billing practices (not disclosing that it had waived the patient’s obligation) are not fraudulent under Pennsylvania state law.

The issue of waiver of patient copays rarely arises with respect to the Medicare program because the Office of Inspector General has issued several guidance documents and fraud alerts waning providers against this particular practice. The OIG and other government agencies have articulated a longstanding position that copay waivers inflate the amount Medicare pays for services.

Aetna Copay Information

In a 1984 OIG Fraud Alert, the OIG commented “if a supplier claims that its charge for a piece of equipment is $100.00, but routinely waives the copayment, the actual charge is $80.00.” The OIG warned providers in the 1984 Fraud Alert that the routine waiver of Medicare copayments and deductibles can result in False Claims Act and Anti-Kickback Statute violations.

In another recent case, a hematology-oncology physician group practice in New York agreed to pay $5.31 million to settle allegations of routinely waiving coinsurance amounts owed by Medicare beneficiaries. According to the complaint filed by a whistleblower, “the physician group routinely waived copayments, without making an individualized determination of financial hardship or exhausting reasonable collection efforts.” Patients were given a pass because they had high balances, said they could not pay, or were frequent patients. According to the complaint, Hudson Valley often waived the associated copayment even if the patient did not request a waiver. Hudson Valley would note the automatic waiver in its billing system by indicating “9212 courtesy write-off.”

Safeguards for Physicians

These cases are a reminder to physicians and other providers to: 1) implement clear, realistic guidelines for evaluating financial hardship; 2) maintain documentation of financial hardship determinations; and 3) engage in reasonable, documented efforts to collect amounts owed by patients. Providers should consider implementing these safeguards for all types of third-party payers, including Medicare and commercial payers.

The information in this article is intended for informational purposes only, and should not be construed as legal advice on the topics addressed. Clay J.Countryman, Esq.,(Clay.Countryman@bswllp.com) is a partner with Breazeale, Sachse & Wilson, LLP, in Baton Rouge, La.

What Insurances Are Waiving Copays