Covid-19 Vaccine and Health Insurance

At present (December, 2020) there are several Covid-19 vaccines in various stages of obtaining approval.  In particular, 2 are likely to hit the U.S. healthcare system in December of this year, from pharmaceutical manufacturers – Pfizer and Moderna – through a process referred to as “emergency use authorization”, or EUA.  The U.S. Food and Drug Administration (FDA) can approve use of vaccines that have made their way through successful clinical trials, for emergency use, before the drugs are authorized for dispensing to the general public.  This blog post addresses some of the pertinent questions relating to the Covid-19 vaccine, such as “who, how, when, and why”.

Approval hearings are scheduled on 12/10/20 and 12/17/20 respectively for the aforementioned pharmaceutical manufacturers.  Once approved, the vaccines are expected to reach healthcare facilities within 24 hours.  There is a very carefully planned 4 phase rollout of the vaccine to various segments of the population as follows:

• – Phase 1a – Healthcare providers/long term care staff and patients
• – Phase 1b – Essential workers
• – Phase 1c – Adults with high risk medical conditions and age 65+ (Note: this “phase 1 group” represents over half of the adult U.S. population.)

• – Phase 2 – K-12 teachers; critical workers in other high risk settings; adults with comorbidities
• – Phase 3 – Young adults (pediatric/adolescent); workers in societally important industries
• – Phase 4 – All others not covered in phases 1-3

The U.S. Centers for Disease Control and Prevention (CDC) estimates that 100 million Americans will receive the vaccine by March of 2021.

The issue of “who pays” for the vaccine is a bit muddled, since there is 2 separate components/charges associated with the vaccine: 1. the serum; and 2. administration of the vaccine.  The federal government has committed to purchasing the vaccine from the various manufacturers (Note: At present, there are 6 pharmaceutical manufacturers petitioning for approval), so there will be no cost associated with the actual vaccine.  The federal government is not, however, picking up the tab for the administration of the vaccine. How, and who pays for the administration of the vaccine will vary depending on whether one has insurance.  Employers with partially self-funded plans will be responsible for covering the cost of administration, while insurance companies will be responsible for the cost on fully insured plans.  Patients will generally not face any cost sharing or fees for either the serum or administration.  Importantly, these initial vaccines are required to be administered in 2 separate dosages, several weeks apart.

For those without health insurance, regulations state that health care providers will be able to get reimbursed through the Health Resources and Services Administration’s Provider Relief Fund, according to the CDC.  Affected patients are encouraged to contact the healthcare facility where they received the immunization in order to have the fee waived.

It’s important to note that insurance coverage for the Covid-19 vaccine is required, during the national state of emergency, by the CARES Act.  Once the health emergency ends, the vaccine will be covered without cost sharing under the preventive care mandate embedded in the Affordable Care Act (ACA).

#####