Will My Health Insurance Cover a COVID-19 Vaccine?

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In most cases, Americans will pay nothing for the COVID-19 vaccine. Government officials know that cost is often an obstacle to obtaining health care, so laws and regulations were implemented soon after the pandemic began 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 (currently effective through April 21, 2021), most people will have access to zero-cost COVID-19 vaccines.

Coverage details may change once the COVID-19 public health emergency is over, assuming that the public will still need COVID-19 vaccination on a regular basis.

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

FG Trade / Getty Images

Medicare

When it comes to COVID-19, advanced age is known to be a significant risk factor for severe complications. Fortunately, virtually all Americans 65 and over are covered by Medicare, and the government has ensured that Medicare beneficiaries can access COVID-19 vaccines at no cost.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted in March 2020, addresses Medicare coverage of COVID-19 vaccines.

Under that law and a subsequent interim final ruling issued in November 2020, Medicare beneficiaries do not have to pay anything for the COVID-19 vaccine or its administration. This is true whether they have Original Medicare, a Medicare Advantage plan, or a Medicare cost plan.

The implementation of these vary only slightly:

  • Original Medicare: COVID-19 vaccines are covered under Medicare Part B, just like influenza and pneumococcal vaccines, with the normal Part B deductible waived.
  • Medicare Advantage: Medicare Advantage plans cover all of the same services that Original Medicare (Parts A and B) do, but they can 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.
  • Medicare cost plans: Original Medicare and Medicare Advantage plans are directly addressed in the CARES Act, but Medicare cost plans are not. However, under the interim final rule, Medicare cost plans will have to provide coverage for COVID-19 vaccines at no cost through the end of the current public health emergency.

The CARES Act specifies that Medicare coverage starts the same day that vaccines are licensed by the Food and Drug Administration (FDA). Under the Public Health Service Act, any emergency use authorization (EUA) granted by the FDA would be regarded as licensure for the duration of the public health emergency.

What this means is that any COVID-19 vaccine granted emergency use authorization by the FDA will be covered fully by Medicare on day one.

The FDA granted its first EUA on December 11, 2020, for the Pfizer-BioNTech COVID-19 vaccine. The Moderna vaccine was granted EUA the following week. The first single-dose COVID-19 vaccine from Johnson & Johnson was granted EUA status on February 27.

Private Health Insurance

More than half of Americans obtain private health insurance through an employer or the individual market (either exchange or off-exchange). The majority of these cover COVID-19 vaccines without any cost-sharing, although there are exceptions.

The CARES Act mandates comprehensive coverage of COVID-19 vaccination for most people with private health insurance. This applies to all non-grandfathered major medical plans in both the individual/family market and group (employer-sponsored) market.

Non-Grandfathered Plans

Under the CARES Act, non-grandfathered individual and employer-sponsored plans are required to cover COVID-19 vaccines, including any charges for administration of the vaccine, without cost-sharing.

This benefit is mandated under the preventive care guidelines of the Affordable Care Act (ACA) and will remain in effect even after the public health emergency ends.

Under normal circumstances, mandated preventive care benefits would only go into effect a year or so after a recommendation is issued either by the U.S. Preventive Care Services Task Force (USPSTF) or the Advisory Committee on Immunization Practices (ACIP).

Under the CARES Act, the process is speeded up. Instead of a year (or, in some case, two), non-grandfathered plans are required to add COVID-19 vaccination to their mandated benefits no more than 15 business days after the issuance of a USPSTF or ACIP recommendation.

What this means is that, for most people with private insurance, coverage would begin the moment a vaccine becomes available (given the lag time between the issuance of a recommendation and the distribution of the vaccine). If in doubt, call your insurance company.

The interim final rule also specifies that private insurance plans must waive all cost-sharing even if a provider bills separately for the cost of the vaccine and the cost of administration. This applies even if the member receives the vaccine from an out-of-network provider.

Grandfathered Plans

The CARES Act does not apply to grandfathered health plans. These are plans purchased on or before March 23, 2010, and account for roughly 14% of all employer-sponsored health plans in the United States.

For these plans, COVID-19 testing is covered with no cost-sharing for the duration of the public health emergency under the Families First Coronavirus Response Act. What may not be covered is the cost of the vaccine or its administration.

Grandfathered health plans have varying approaches to this shortcoming. In some cases, the state might step in and require some or all of these plans to waive cost-sharing.

In other cases, a plan could voluntarily agree to do so. This is most likely with employer-sponsored plans, since the employer would benefit directly from keeping their staff healthy and safe from COVID-19.

Plans Not Regulated by the ACA

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

At least 3 million Americans have coverage under short-term health plans, while 1.5 million are enrolled in healthcare sharing ministry plans.

Although some non-ACA-regulated insurers may agree to voluntarily include COVID-19 vaccination in their benefits, be aware that they may or may not fully waive cost-sharing.

Liberty HealthShare, one of the most popular healthcare sharing ministry plans, is one such example, having already stated that vaccine costs will be shareable. Other ministry plans have done the same, sometimes requiring members to meet their normal "annual unshared amount" (similar to a health insurance deductible) before the vaccine cost is shared.

If you're covered under any of these plans, reach out to the company to see if and how they will cover the cost of a COVID-19 vaccination.

Grandmothered 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, both of which are already required to cover preventive services under the ACA.

Medicaid

Under the Families First Coronavirus Response Act, states are eligible to receive additional Medicaid funding during the COVID-19 public health emergency as long as they comply with several basic requirements. This includes ensuring that beneficiaries have coverage for COVID-19 testing, treatment, and vaccines with zero cost-sharing.

All states are currently receiving 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 ends, Medicaid coverage could vary depending on the person's eligibility category. Even so, the majority of enrollees will likely have access to zero-cost COVID-19 vaccines. This includes children and adults who are eligible under the ACA's expansion of Medicaid.

States will have the option to continue zero-cost coverage COVID-19 vaccines for these groups but are not required to do so under the current rules.

Medicaid enrollees who may not benefit include those whose eligibility is based on pregnancy, disability, or being a parent/caretaker of a minor child.

Children's Health Insurance Program (CHIP)

Children's Health Insurance Program (CHIP) coverage is mandated to cover all ACIP-recommended vaccines for children through age 19 with zero cost-sharing.

So once a COVID-19 vaccine received ACIP recommendations, it will be fully covered under CHIP. With that said, it is only covered for the recommended age groups. Currently, the Pfizer vaccine recommendations only extend to people 16 and over, while the Moderna and Johnson & Johnson vaccines are only approved for people 18 and over. This could change based on vaccine trials currently underway in children.

In addition to children, some states also provide CHIP coverage for pregnant women and have opted to provide recommended vaccines with zero cost-sharing as part of that coverage.

Basic Health Programs

Basic Health Programs are currently in effect in Minnesota and New York. These programs provide affordable health coverage to people with incomes up to 200% of the federal poverty level (FPL) and offer fairly minimal out-of-pocket costs.

These state-sponsored programs are required to provide coverage for the ACA's essential health benefits (EHBs), including preventive care with zero cost-sharing.

The interim final rule further stated that Basic Health Programs must fully cover these costs regardless of whether the vaccine is administered by an in-network or out-of-network provider.

A Word From Verywell

For most people, the limiting factor for COVID-19 vaccination won't be health coverage but rather the availability of the vaccine. Once your turn comes, your health insurance will almost certainly cover the cost regardless of where you receive the vaccine.

If you're uninsured or have a health plan with no such benefit, you may still be eligible to get a no-cost vaccination through federal programs created to assist uninsured Americans.

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Article Sources
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