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FACT SHEET:
Health Insurance Coverage of Testing, Vaccines, and Treatment
After the Federal Public Health Emergency for COVID-19
Ends on May 11, 2023
With the end of the federal public health emergency (PHE) for COVID-19 on
May 11, 2023, certain federal provisions requiring coverage of COVID-19
diagnostic testing without cost sharing will end. However, if you are in a health
insurance policy that is regulated by the state of California, most coverage
requirements are permanent. This Fact Sheet is to inform consumers about
the changes to the coverage requirements for COVID-19 testing, vaccines
and therapeutics following the termination of the PHE.
What policies does state law cover?
If you are in a health insurance policy regulated by the California Department
of Insurance, or a health plan regulated by the Department of Managed
Health Care, then the state law requirements in this Fact Sheet apply to your
coverage. All health policies and plans sold in the individual market, including
through Covered California, are regulated by the state.
If you are in an employer-sponsored plan that is regulated by the U.S.
Department of Labor or U.S. Department of Health and Human Services, then
state law doesn’t apply.
A self-funded employer plan is a health plan that is
sponsored by an employer rather than an insurance company. On most self-
funded insurance ID cards, the insurance company will be identified as the
plan administrator. You can also ask your employer to confirm which type of
coverage you have.
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What are the current coverage requirements?
Health insurers regulated by the state of California are currently required to
cover the following free of charge to patients:
• COVID-19 diagnostic testing, including over-the-counter (OTC) COVID-
19 tests, and any health care items or services that are necessary for
delivery of the testing.
• COVID-19 vaccines, and any health care items or services that are
necessary for delivery of the vaccine.
i
• COVID-19 therapeutics, including Paxlovid, Legevrio, and Veklury
(remdesivir) administration.
ii
Regardless of whether you receive these benefits from an in-network or out-
of-network provider, your health insurer must cover the benefits without
medical management, including prior authorization. In addition, health
insurers must cover COVID-19 testing, vaccines, and therapeutics without
cost sharing, including a deductible, copayment, or coinsurance.
How long will the current coverage requirements stay in place?
Requirements for health insurers to cover COVID-19 testing, vaccines,
therapeutics, and related health care benefits from an in-network provider
without out-of-pocket cost are permanent.
iii
However, the same requirements
for covering COVID-19 vaccines, testing, and treatment without cost sharing
when delivered by an out-of-network provider expire six months after the
federal public health emergency ends, on November 11, 2023.
If you are in an employer-sponsored (self-funded) health plan that is regulated
by the U.S. Department of Labor or the U.S. Department of Health and
Human Services, then the federal rules apply and your coverage for
COVID-19 diagnostic testing may change at the end of the federal PHE on
May 11, 2023. However, federal requirements to cover COVID-19
immunizations without cost sharing when delivered by an in-network provider
will not expire.
iv
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How will coverage requirements change after November 11, 2023?
Starting November 12, 2023, you may have to pay cost sharing for the
following services if you have coverage for benefits on an out-of-network
basis and received them from an out-of-network provider or pharmacy:
• COVID-19 diagnostic testing services and related health care.
• COVID-19 vaccines and any items or services necessary for the delivery
of the vaccine.
• COVID-19 therapeutics.
v
Remember that even if you have coverage for benefits on an out-of-network
basis, your out-of-pocket cost for using those benefits will be more than if you
access your benefits from in-network providers and pharmacies.
The following chart summarizes the information in this fact sheet.
Insurance provider
Benefits
Cost protections
California regulated
insurance – in-network
provider
COVID-19 diagnostic
testing, including OTC
tests; vaccines;
therapeutics
Permanently covered
free of charge
California regulated
insurance – out-of-
network provider
COVID-19 diagnostic
testing, including OTC
tests; vaccines;
therapeutics
Covered free of charge
until November 11,
2023
Federally regulated
insurance – in-network
provider
COVID-19 vaccines
Permanently covered
free of charge (unless
health plan is
grandfathered)
Federally regulated
insurance – in-network
and out-of-network
provider
COVID-19 diagnostic
testing
Cost sharing may
apply, and OTC tests
may not be covered
after May 11, 2023
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Where can I go for help?
Our Department’s Consumer Services staff are ready to help answer your
COVID-19 health insurance coverage questions in many languages. Contact
our consumer hotline at 800-927-4357.
i
Items or services include, but are not limited to, office visits and vaccine administration.
ii
CIC § 10110.7, subd. (b) & (b)(2); CIC § 10110.7, subd. (c)(4)(A) & (c)(5); CIC § 10110.7, subd. (i)(4) &(i)(5).
iii
CIC § 10110.7, subd. (b)(5); CIC § 10110.7, subd. (c)(4)(E), CIC § 10110.7, subd. (i)(5).
iv
CMS, FAQ 58 (March 29, 2023) at https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqs-part-58.pdf.
v
CIC § 10110.7, subd. (b)(5); CIC § 10110.7, subd. (c)(4)(E) & (c)(5); CIC § 10110.7, subd. (i)(4).
