Call for Action: What COVID issues are health insurances companies required to cover?

Local woman calls for help after her mom spend 3 months in the hospital

When you’re dealing with the long-term effects of COVID-19, the last thing you want is a health insurance company deciding you don’t get the treatment you need to get better. But according to 78-year-old Karen Nelson’s family, that’s what happened to their matriarch.

Karen’s daughter, Tanya Williams, has been leading the battle against health insurance company Aetna to get her mother the care she needs. After three months in the hospital, Williams says doctors repeatedly referred Karen to a long-term care facility, where she could receive rehabilitation and a better chance at returning home. Aetna, however, continually denied that referral.

“It’s probably one of the hardest things I’ve ever been through,” Williams said. “To see my mom, who is so vibrant in what she does for her family every day – to see her lying in a hospital bed, not getting the care that she needs to come home to us, and knowing that an insurance company is what’s holding us back.”

News 3 Now’s Call for Action team contacted Aetna on Karen’s behalf. Within days of the first email and after three previous refusals, the health insurance company reversed course and approved Karen’s transfer.

A spokesperson for the company told News 3 Now in an email that “prior requests for transfer were not approved because her clinical condition was determined to not be medically necessary or appropriate for LTACH care under Medicare rules, following reviews by both Aetna medical professionals and an independent medical review.” Aetna said its reversal came after Karen’s healthcare providers updated them of her progress.

How many people are in Karen’s position across Wisconsin? What exactly are health insurance companies required to cover? We asked the state’s Office of the Commissioner of Insurance. They told us per CDC guidelines, health insurers are required to cover COVID-19 vaccines and diagnostic testing – those nasal swabs you might have received to see if you’ve gotten the virus. Treatment, though, is trickier. All coverage depends on your health insurance provider, but the OCI has sent out a series of bulletins to guide Wisconsin-based companies. A bulletin from December strongly encourages insurance companies to remove barriers, like out-of-pocket payments, or long pre-authorization procedures. But that’s just a recommendation.

“We put in place requirements where we can, and we strongly encourage when we don’t have the ability to do something,” said Nathan Houdek, deputy insurance commissioner for the state of Wisconsin.

Regardless of the lack of teeth, it doesn’t seem like too many health insurance issues have been raised. An OCI open records request only found 18 documented complaints. That number has the OCI reminding folks its employees can help mediate issues on your behalf if you’re running into trouble with your health insurance company.

“This is a really challenging time, and people don’t have answers to all the questions, and that’s where we can be helpful,” Houdek said.

To file a complaint with the OCI and start the process of mediation, click here. You can also call 1-800-236-8517 to find help.