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.