On December 10th the Pfizer/BioNTech’s COVID-19 vaccine and on December 18th Moderna with their mRNA-1273 vaccine received the FDA emergency release authorization for their Covid-19 vaccines. Due to the fact that initial supply is scarce in comparison to demand, the first priority of the initial distribution of the vaccine has been allocated to health care personnel and residents of long-term care facilities. The CDC estimates that in the USA approx. 20 Mio health care professionals and residents of long-term care facilities will have access to the vaccine by the end of December.
All health insurance carriers are in the process of sending messages to their policyholders about how they will handle the distribution and cost of the Covid-19 vaccine. Currently, federal rules bar health insurance companies from applying any cost-sharing to insurance members for any COVID-19 testing and treatment from providers. The Affordable Care Act also requires any recommended preventative services such as vaccines to be fully covered by your health insurer.
However, this is America where surprise billing is possible. Out-of-network doctors who do not have contracts with your health insurer and administer the vaccine are required by the CDC to accept the Medicare rate for administering the vaccine at $16.94 for the first dose and $28.39 for the second dose. Furthermore, many members are on grandfathered health insurance plans which are exempt from the CARES Act and are not required to fully cover the vaccine or any other preventative services.
The distribution of the vaccine is an enormous task. The CDC has given out the distribution guidelines for phase 1. First priority will be given to health care personnel and residents of long-term health care facilities. They will likely be followed by the elderly, people with high-risk comorbidities, and essential workers. The further phases are still not clear and are left to states and local officials on how to successfully implement.
It is strongly advised to check with your health insurance carrier on which preferred pharmacy and doctor office will be their preferred network. Major pharmacy retailers such as CVS, Walgreens, and other major pharmacy retailers will play a major role in the task to vaccinate all Americans once the vaccine is widely available. The biggest concern to insured members is around vaccine administration; if you are receiving your vaccination at an out-of-network provider, you likely will have to pay administrative fees. In addition, if you explain to your provider about pre-existing conditions, they may try to charge you for a doctor visit as well.
In summary, although the COVID-19 vaccination should be free, please take precautions by going to an in-network provider to avoid surprise billing. If you are only going for the vaccination and nothing else, do not discuss pre-existing conditions to avoid doctor visit charges. The Affordable Care Act & CARES Act both will provide strong protections to patients although there is always the risk of surprise billing, especially if you do not receive your vaccine at an in-network provider.
To better understand coronavirus coverage by your health insurer, please contact us or your health insurer’s member services line for further assistance. At Solid Health Insurance Services, we strive to find our clients the right health, dental, vision, life, and long-term care insurance that best fits their budget and medical needs. Please contact us at 310-909-6135 or at info@solidhealthinsurance.com for us to better assist you.