With the talk of the Covid-19 vaccine taking center-stage, it is obvious for the people to think that whether the cost of the vaccine will be covered under their plans or not. With the first phase of vaccination already started in the U.S. people need to know that in a majority of the cases they don’t have to pay anything for the COVID-19 vaccine. It was known by the Government officials that the vaccine cost will be an obstacle for people to get this vaccine, so in early 2020 laws and regulations were implemented to ensure that people have access to the vaccine at no cost. For the entire duration of the public health emergency, people will have access to zero cost Covid-19 vaccines. However, in later years the coverage details will differ in some cases, especially when this pandemic is over. It is assumed that people will need to receive this vaccine regularly.
Check COVID-19 Vaccine Coverage Status under Different Plans:
We are very well aware that seniors are at great risk of COVID-19, so all Americans over 65 years of age, who are covered by Medicare have been ensured by the government to have access to this vaccine free of cost. Section 3713 of the CARES Act that was enacted in March 2020 addresses COVID-19 coverage under Medicare. According to this act, Medicare beneficiaries are not required to pay anything for the vaccine or its administration. This is applicable, whether seniors have Original Medicare, a Medicare Advantage plan, or a Medicare cost plan. The vaccine is covered under Medicare Part B like influenza and pneumococcal vaccines with the normal Part B deductible waived.
Medicare Advantage and Medicare Cost Plans
Medicare Advantage and Medicare Cost Plans generally cover the same healthcare services that are covered under Original Medicare but these usually have different cost-sharing amounts. However, as far as this vaccine is concerned, the interim final rule clarifies that Medicare Advantage plans cannot impose cost-sharing for the vaccine or its administration. The CARES Act has directly addressed this vaccine coverage for Original Medicare and Medicare Advantage plans but not about Medicare cost plans. Thus, the interim final rule included a clarification that even the Medicare cost plans would have to provide coverage for this vaccine to enrollees free of cost, at least till the end of the current public health emergency.
The CARES Act specifies that COVID-19 vaccine coverage under Medicare starts on the day on which vaccines obtain licensed by the FDA under Section 351 of the Public Health Service Act. The first emergency use authorization was granted by the FDA on December 11, 2020, for the Pfizer BioNTech COVID-19 vaccine for people age 16 and older.
Private Health Insurance Plans
Over half of the residents of America have coverage under private health insurance plans, either purchased by themselves or provided by their employers. The majority of these plans will provide coverage for COVID-19 vaccines without any cost-sharing, though there may be some exceptions. For most of the people having private health insurance plan, the CARES Act has ensured comprehensive coverage of the vaccine. The law even applies to all non-grandfathered major health plans in both the individual and group health insurance markets.
Non-grandfathered health plans under the CARES Act are required to cover COVID-19 vaccines, along with the administration charges of the vaccine. The members of these plans do not require to pay any cost-sharing for getting this vaccine. This specific benefit falls under preventive care as per the ACA guidelines but this will be quickly implemented than any new preventive care guidelines would be implemented. According to the interim final rule issued in November 2020, all private health insurance plans should waive all cost-sharing for the vaccines, even if the healthcare provider has separately billed for the vaccine cost and its administration cost. It also states that the insurance carriers should provide this zero-cost-sharing coverage even if members receive the vaccine from an out-of-network healthcare provider.
The grandfathered plans are required to cover COVID-19 testing with no cost- sharing for the enrollees for the duration of public health emergency as per the Families First Coronavirus Response Act terms. However, the vaccine coverage requirements do not extend to grandfathered plans because the CARES Act and the interim final rule do not apply to grandfathered health plans. Grandfathered plans have different approaches to COVID-19 vaccine coverage, as in some cases, states might require some plans to cover the vaccine without any cost-sharing to members of the plans. However, this will be mostly with employer-sponsored grandfathered plans, as employers wish to keep their employees healthy so they wish to provide increased access to the COVID-19 vaccine to their employees.
Plans that are not Regulated by the ACA
Health plans that are not regulated by the ACA like short-term health plans, fixed indemnity plans, health care sharing ministry plans, and farm bureau plans do not provide coverage for the COVID-19 vaccine as per the Federal rules. Though some of these less-regulated health plans may voluntarily agree to cover this vaccine cost, but they may or may not agree to completely waive off cost-sharing for the members of the plan. Individuals who are not covered under the ACA-compliant plan will need to check with their specific plan regarding the COVID-19 vaccine coverage. If their plan does not provide coverage for the vaccine, then they can check with the government programs that have been created to assist uninsured Americans to get a no-cost vaccine.
Grandmothered and Self-Insured Plans
Both grandmothered and self-insured plans are required to cover COVID-19 vaccines with zero cost-sharing, as these plans are required to cover preventive services under the ACA that also include recommended vaccines.
The Families First Coronavirus Response Act that was enacted in March 2020 allows states to receive additional federal Medicaid funding during public health emergency like the COVID-19, provided the states fulfill some basic requirements like ensuring that all Medicaid beneficiaries will have coverage for COVID-19 testing, treatment, and vaccines, with zero cost-sharing. Since all states are receiving this additional Medicaid federal funding, so beneficiaries will have access to COVID vaccines at no-cost. Individuals need to know that this vaccine coverage requirement does not apply to limited benefit Medicaid programs that only provide coverage for tuberculosis or family planning-related services.
After this public health emergency period ends, the COVID-19 vaccine coverage for the Medicaid beneficiaries will depend upon the person’s eligibility category, however, the majority of enrollees like children and adults eligible under the ACA’s Medicaid expansion are likely to have access to the zero-cost vaccine. However, for individuals eligible for Medicaid based on disability, pregnancy, or being a parent or caretaker of a minor child, then the requirement for vaccine coverage will vary from one state to another for such populations. States is they wish can continue to provide zero-cost vaccines for these groups but are not required to provide vaccine coverage as per the current rules.
Children’s Health Insurance Program (CHIP)
If the COVID-19 vaccine is recommended by ACIP, then CHIP is required to provide coverage for the vaccine for children through the age of 19 years with zero cost-sharing for the vaccine or its administration. Thus, all the children enrolled in CHIP will be fully covered for this vaccine. The states that provide CHIP coverage to pregnant women have also opted to provide this vaccine with zero-cost-sharing as part of the coverage.
Basic Health Programs
Basic Health Programs effective in Minnesota and New York provide affordable health coverage to people with income up to 200% of the poverty level. These programs come with fairly minimal out-of-pocket costs and are required to provide coverage for preventive health care with zero cost-sharing that includes any vaccines recommended by ACIP. The federal government in the interim final rule clarified that Basic Health Programs should provide this vaccine coverage, irrespective of whether the vaccine was administered by an in-network or out-of-network provider.
Finally, it can be said that for the majority of the people, the issue won’t be health insurance coverage but the issue will the vaccine availability based on FDA approval criteria, and the CDC developed hierarchy, which is the order in which the population will receive the vaccine. Once an individual’s term comes, then it is almost certain that his/her health plan will cover the vaccine cost and its administration, regardless of where the person receives the vaccine.