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Commercialization of COVID-19 Vaccines, Treatments, and Tests: Implications for Access and Coverage [1]

['Jennifer Kates', 'Cynthia Cox', 'Juliette Cubanski', 'Jennifer Tolbert', 'Karen Pollitz']

Date: 2023-01-27 15:11:53+00:00

When the government-purchased inventory of COVID-19 vaccines is depleted, Medicare will determine a payment rate for the vaccines and update the payment allowance for providers. Medicare will then pay providers for the vaccine itself along with administration of the vaccine.

Medicare pays providers for COVID-19 vaccine administration , but not for the vaccine itself, since the vaccine is free to providers through the US government purchased inventory.

Once the supply of government-purchased vaccines runs out, the Vaccines for Children Program (VFC) will provide access to COVID-19 vaccines for Medicaid-eligible children. The VFC program will purchase the vaccine and make it available to VFC-registered providers. Providers can bill Medicaid for costs of administering the vaccines. For other Medicaid and CHIP enrollees, states will pay providers for the vaccine plus an administration fee. These state Medicaid and CHIP costs will be matched at the state’s regular and enhanced (for CHIP) FMAPs.

States will receive 100% federal matching payments for the costs associated with administering the vaccine through the end of the last day of the first quarter that begins one year after the PHE ends. After that, state costs will be matched at the state’s regular federal matching percentage (FMAP) and enhanced FMAP for CHIP.

PRIVATE

No one with private insurance should be asked to pay for federally-purchased COVID vaccines, including boosters, or for vaccine administration. Vaccine providers participating in the CDC COVID-19 Vaccination Program (i.e., those receiving federally-purchased vaccine doses) may seek reimbursement from private health insurers for the cost of administering the vaccine, but they are prohibited from billing patients even if the patient’s health plan does not reimburse the provider or does not cover the full cost of the vaccine administration. Most private insurers will reimburse vaccine providers for administration costs, in part because the Affordable Care Act (ACA) requires most plans to cover preventive services, including any vaccine recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP), as all COVID-19 vaccines in the U.S. are. While the ACA requires coverage of ACIP-recommended vaccines no later than one year after their recommendation, the CARES Act shortened this to 15 days for COVID-19 vaccines. This is irrespective of whether the vaccine is under an emergency use authorization or fully approved by the FDA. Even in cases when the insurer is not subject to the ACA coverage requirement (e.g. for out-of-network care or grandfathered health plans), the patient cannot be billed for the vaccine, its administration, or the associated visit if the vaccine dose was purchased by the federal government. In cases when private plans do not cover or do not fully cover the cost of the vaccine, vaccine providers were able to submit claims for reimbursement from the federal government. However, due to a lack of funding, the federal government stopped accepting these claims on April 5, 2022. Even so, providers cannot bill patients for any amount not reimbursed so long as they are administering government purchased COVID-19 vaccines.

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[1] Url: https://www.kff.org/coronavirus-covid-19/issue-brief/commercialization-of-covid-19-vaccines-treatments-and-tests-implications-for-access-and-coverage/

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