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COVID-19 Vaccine FAQs

posted by AHIP

on January 12, 2021

How is the COVID-19 vaccine covered by health insurance providers?

  • Health insurance plans that are compliant with the Affordable Care Act (ACA) are required to cover vaccines without cost sharing for in-network and out-of-network.
  • Health insurance providers are required to cover related items and services if the primary purpose of the visit is the COVID-19 vaccine.
  • Health insurance providers have 15 business days from the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practice (ACIP) recommendation to cover a vaccine and are encouraged to cover as soon as possible.
  • Grandfathered plans and other “underinsured” plans – that is, those that are not required to be ACA-compliant – are not required to cover vaccines without cost sharing.
  • People on grandfathered plans and other “underinsured” will qualify as uninsured or underinsured, with administration fees paid by HRSA.

How is vaccination data shared with health insurance providers?

  • Vaccination information will be transmitted to health insurance providers through claims for administration charges.
  • Providers (and sites) will input patient information into the CDC’s Immunization Information Systems (IIS) or federal systems, which will then be ready for analysis.
  • Some health plans have access to the CDC’s IIS.

How are COVID-19 vaccines being coded and billed?

  • The Centers for Medicare & Medicaid Services (CMS) has indicated no preference for billing COVID-19 vaccines as a medical or pharmacy benefit.
  • The American Medical Association (AMA) Current Procedural Terminology (CPT) committee has released coding conventions for COVID-19 vaccines that include specific vaccine and dose information.
  • The National Council for Prescription Drug Programs (NCPDP) has created a coding convention that differentiates between doses of a vaccine.
  • Medicare will pay $28.39 for administration of a single-dose COVID-19 vaccine, or $16.94 for the first dose and $28.39 for a final dose of a multi-dose vaccine.

What’s the timing and availability for COVID-19 vaccines?

  • Vaccines must be approved by the Food and Drug Administration (FDA) under an Emergency Use Authorization (EUA) or Biologics License Application (BLA), then recommended by ACIP.
  • Vaccines do not need to be recommended as “routine” by ACIP.
  • Plans are required to cover vaccines within 15 business days of ACIP recommendation.
  • ACIP will make allocation recommendations; states and jurisdictions will ultimately decide who receives vaccines when.
  • CVS and Walgreens will establish clinics in long-term care facilities.

How are Americans getting educated about the COVID-19 vaccine and when to get their second dose?

  • Health insurance providers intend to educate their members about the safety and efficacy of COVID-19 vaccines. To improve health equity, health insurance providers will target disadvantaged, underserved communities.
  • Operation Warp Speed will use V-Safe, a text messaging program, as well as calls, physical cards, and other communications to remind people when to get their second dose of the COVID-19 vaccine.

 

How is the COVID-19 vaccine being administered in Long-Term Care Facilities?

  • CVS, Walgreens, and Managed Health Care Associates (MHA) will set up clinics in long-term care facilities (LTCFs), skilled nursing facilities (SNFs), and other non-independent living homes for the administration of COVID-19 vaccines.
  • They will conduct 3 clinics at each site – first dose, second dose, and one for missed second doses.
  • States/jurisdictions will decide program enrollment and prioritization – each selects a single vaccine for administration in all LTC facilities.
  • Insurance plans will receive claims for administration of vaccines under these programs.