Will My Health Insurance Cover a COVID-19 Vaccine?

In most cases, people may have to pay nothing for the COVID-19 vaccine. Government officials know that cost is often an obstacle to obtaining healthcare, so laws and regulations were implemented earlier in 2020 to ensure that most people would be able to access the vaccine at no cost.

Since American health insurance coverage is far from uniform, it is important to learn and understand specifics about your plan. For the duration of the public health emergency, most people will have access to zero-cost COVID-19 vaccines. In some cases, coverage details will differ in later years, once the COVID-19 public health emergency is over, assuming we have to continue to receive COVID-19 vaccines on a regular basis.

Older Black man wearing a mask and receiving a vaccine from a medical provider

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Medicare

When it comes to COVID-19, we've long known that advanced age is a significant risk factor. Fortunately, virtually all Americans age 65+ are covered by Medicare, and the government has ensured that Medicare beneficiaries can access COVID-19 vaccines at no cost.

Section 3713 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which was enacted in March 2020, addresses Medicare coverage of COVID-19 vaccines. Under that law and a subsequent interim final rule issued by several federal agencies in November 2020 (and in effect for the duration of the COVID-19 public health emergency), Medicare beneficiaries do not have to pay anything for the COVID-19 vaccine or its administration. This is true whether they have Original/Traditional Medicare, a Medicare Advantage plan, or a Medicare cost plan.

COVID-19 vaccines are covered under Medicare Part B, just like influenza and pneumococcal vaccines, with the normal Part B deductible waived. Medicare Advantage plans and Medicare cost plans are required to cover all of the same services that Original Medicare (Parts A and B) covers, but they can generally have different cost-sharing amounts. For the COVID-19 vaccine, however, the interim final rule clarifies that private Medicare Advantage cannot impose any cost-sharing for the vaccine or its administration.

What About Medicare Cost Plans?

Medicare Advantage plans and Original Medicare are directly addressed in the CARES Act, but Medicare cost plans are not. So the interim final rule added a clarification that cost plans would have to provide coverage for COVID-19 vaccines at no cost to enrollees, at least through the end of the current public health emergency.

The CARES Act specifies that Medicare coverage of COVID-19 vaccines starts the same day that such vaccines are licensed by the FDA under Section 351 of the Public Health Service Act. The interim final rule clarifies that any emergency use authorizations granted by the FDA during the COVID-19 public health emergency would count as licensure under Section 351 of the PHS Act.

So any COVID-19 vaccines that have been authorized by the FDA and are available for public use will be fully covered by Medicare from day one. The FDA granted its first emergency use authorization on December 11, 2020, for the Pfizer-BioNTech COVID-19 vaccine for people age 16 and older.

Private Health Insurance

More than half of all Americans are covered under private health insurance that's either provided by an employer or purchased in the individual market (through the exchange or off-exchange). The majority of these health plans will cover COVID-19 vaccines without any cost-sharing, although there are some exceptions.

Section 3203 of the CARES Act ensures rapid and comprehensive coverage of the COVID-19 vaccine for most people with private health insurance. The law applies to all non-grandfathered major medical plans in both the individual/family and group (employer-sponsored) markets.

Non-Grandfathered Plans

Under the CARES Act, non-grandfathered individual and employer-sponsored health plans are required to cover COVID-19 vaccines, including any charges for administration of the vaccine, without requiring the plan member to pay any cost-sharing. This benefit will fall under the preventive care guidelines of the Affordable Care Act (ACA), but it will be implemented much faster than new preventive care guidelines normally would be. And it's a permanent requirement, which will remain in effect even after the COVID-19 public health emergency ends.

Under normal rules, new preventive care recommendations made by the U.S. Preventive Care Services Task Force (USPSTF) or the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) are only required to be fully paid by health insurance plans starting with the plan year that begins at least one year after the recommendation is made. This can potentially result in a delay of up to two years if a recommendation is made very soon after a health plan renews. This could happen if the following renewal would be less than a year after the recommendation was made, and another plan year would go by before the coverage had to be added to the plan. To avoid this, the CARES Act specifies that no-cost coverage of COVID-19 vaccines must begin under non-grandfathered individual and group health plans no more than 15 business days after the USPSTF or ACIP makes a recommendation that a COVID-19 vaccine is added to the preventive care guidelines.

On December 12, 2020, just hours after the FDA issued an emergency use authorization for the Pfizer-BioNTech COVID-19 vaccine for people age 16 and older, the ACIP held an emergency meeting to vote on a recommendation for the vaccine (you can see the live stream of the meeting here). Two separate votes were held: One specific to the Pfizer-BioNTech vaccine, and one for a general recommendation to add a vaccine for COVID-19 to the normal vaccine schedule, to ensure that there's coverage for additional vaccines without delay, as they're approved by the FDA. The 14 member committee voted unanimously for the general recommendation. And the vote for the Pfizer-BioNTech vaccine recommendation was 11-0, with three members recusing themselves due to conflicts of interest.

CDC Director Robert Redfield signed off on the recommendation almost immediately. Now that the recommendation is official, non-grandfathered health insurance plans will have 15 business days to add the zero-cost COVID-19 vaccine to their covered benefits. For most people, the coverage will kick-in well before the vaccine is actually available to them, given the protocol that the CDC is using to allocate vaccines initially.

The interim final rule issued in November 2020 clarifies all of the health insurance requirements in detail. It specifies that private insurance plans must waive all cost-sharing for COVID-19 vaccines, even if the medical provider bills separately for the cost of the vaccine and its administration. And it notes that the insurer must provide this zero-cost-sharing coverage even if the member receives the vaccine from an out-of-network medical provider.

Grandfathered Plans

The CARES Act and the interim final rule do not apply to grandfathered health plans (grandfathered plans are required to cover COVID-19 testing with no cost-sharing for the duration of the public health emergency, under the terms of the Families First Coronavirus Response Act, but the requirements for vaccine coverage do not extend to grandfathered plans). About 14% of all workers with employer-sponsored health coverage are covered under grandfathered plans.

Grandfathered health plans may have varying approaches to COVID-19 vaccine coverage. In some cases, states might step in and require some of these plans to cover the vaccine and waive cost-sharing, as some states did with regards to short-term health plans and COVID-19 testing. In other cases, these plans could voluntarily agree to provide coverage for COVID-19 vaccines. This might be likely among grandfathered employer-sponsored plans, as keeping their employees healthy is a primary concern and increased access to a COVID-19 vaccine is a good move in that regard.

Plans Not Regulated by the ACA

The vaccine coverage requirement does not apply to plans that are not regulated by the ACA. These include:

Federal rules do not require any of those types of coverage to pay for any preventive services, including a COVID-19 vaccine. At least 3 million people have coverage under short-term health plans, while 1.5 million are enrolled in health care sharing ministry plans.

Some of these less-regulated health plans might agree to voluntarily cover COVID-19 vaccines, although they may or may not agree to fully waive member cost-sharing. For example, Liberty HealthShare, one of the most popular health care sharing ministry plans, has already said that COVID-19 vaccine costs will be shareable, although they have not clarified whether the member will still have to meet their normal "annual unshared amount" (sort of like a deductible on health insurance plans) before the vaccine cost would be paid via the sharing ministry plan.

If you're covered under a health plan that's not subject to the ACA's requirements and/or not considered health insurance at all (e.g., a sharing ministry plan, or a Farm Bureau plan in states that have exempted these plans from insurance laws and regulations), you'll want to reach out to your plan to see specifically if and how they will cover COVID-19 vaccines. If you have no coverage for the vaccine, you may still be eligible to get a no-cost vaccine through programs that have been created to assist uninsured Americans.

Grandmothered Plans and Self-Insured Plans

The requirement that COVID-19 vaccines be covered with zero cost-sharing does apply to grandmothered (transitional) plans and non-grandfathered self-insured plans, as those are already required to cover preventive services under the ACA, including recommended vaccines.

Medicaid

Under the Families First Coronavirus Response Act, which was enacted in March 2020, states are eligible to receive additional federal Medicaid funding during the COVID-19 public health emergency, as long as the states comply with several basic requirements—one of which is ensuring that Medicaid beneficiaries have coverage for COVID-19 testing, treatment, and vaccines, with zero cost-sharing. All states are receiving this additional federal funding, so virtually all Medicaid beneficiaries will have access to zero-cost COVID vaccines.

But the COVID-19 vaccine coverage requirement does not extend to limited benefit Medicaid programs, such as those that provide Medicaid coverage only for family planning services or tuberculosis-related services.

After the COVID-19 public health emergency period ends, Medicaid coverage of the COVID-19 vaccine could vary depending on the person's eligibility category, but the majority of enrollees will likely continue to have access to zero-cost COVID-19 vaccines. This includes children, as well as adults who are eligible under the ACA's expansion of Medicaid. But it does not include, for example, adults whose eligibility is based on pregnancy, disability, or being a parent/caretaker of a minor child, and current vaccine coverage generally varies considerably from one state to another for these populations. States will have the option to continue to provide zero-cost COVID-19 vaccines for these groups (and may do so in the interest of public health), but would not be required to do so under current rules.

Children's Health Insurance Program (CHIP)

Children's Health Insurance Program (CHIP) coverage is required to provide any ACIP-recommended vaccines for children through age 19, with zero cost-sharing for the vaccine or its administration. So once the COVID-19 vaccine is recommended by ACIP, it will be fully covered for children enrolled in CHIP. Some states also provide CHIP coverage for pregnant women and have opted thus far to provide recommended vaccines with zero cost-sharing as part of that coverage.

Basic Health Programs

Basic Health Programs are in effect in Minnesota and New York (any state has the option to create one, but only those two states have chosen to do so). These programs provide affordable health coverage to people with income up to 200% of the poverty level, with fairly minimal out-of-pocket costs. They are required to provide coverage for the ACA's essential health benefits, including preventive care with zero cost-sharing (and this includes any vaccines recommended by ACIP).

In the interim final rule that was issued in November 2020, the federal government clarified that for the duration of the public health emergency, Basic Health Programs must provide coverage of COVID-19 vaccines with zero cost-sharing, regardless of whether the vaccine is administered by an in-network or out-of-network provider (i.e., the same rules that apply to private non-grandfathered individual and group health plans).

A Word From Verywell

For most people, the limiting factor won't be health insurance coverage, but will instead be the availability of the vaccine based on FDA approval criteria (approval for a vaccine for children under the age of 16 will come later, for example) and the hierarchy that the CDC has developed in terms of the order in which populations should receive the vaccine. Once your turn comes, your health insurance will almost certainly cover the cost of the vaccine and its administration, regardless of where you receive the vaccine.

If you're uninsured or covered under a health plan that doesn't have to provide coverage for COVID-19 vaccines, you may still be able to get the vaccine at no cost, under programs that have been established to provide COVID-19 testing, treatment, and vaccines for uninsured Americans.

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Article Sources
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