Health Coverage for COVID Vaccines - Explained

the centers for medicare and medicaid services have begun planning for covid vaccine coverage considerations this is in preparation for when a vaccine ultimately becomes available cms released their planning documents on october 28th that included measures to remove regulatory barriers and include some consistent coverage and payment information for an eventual vaccine cms also released a tool kit helpful for providers for states and for

insurers to help start making some of these early preparations now again no vaccine is available at this time this is all planning and cms said their goal is first of all to increase the number of providers that can administer a vaccine and also ensure adequate reimbursement in medicare and start thinking about private insurance and medicaid coverage they said they want to make clear to private insurers and medicaid programs their responsibility to cover the vaccine

at no charge to beneficiaries it was released in what is called an interim final rule first it says that any vaccine that receives fda authorization will be covered under medicare as a preventative vaccine at no cost to beneficiaries this interim final rule also includes provisions for activating or implementing part of the cares act that says certain private health insurance plans must provide coverage without cost sharing for qualifying

coronavirus preventative services and a covet immunization or cova vaccine would qualify as a coronavirus preventative service now said certain private health insurance plans must provide this that would be group health plans or health insurance issuers offering group or individual coverage that is considered non-grandfathered and there are distinctions of what's a grandfathered or non-grandfathered plan grandfathered is a plan that has rolled over from a previous year without necessarily having to meet a lot

of the current day requirements of health insurance plans meeting things like the essential health benefits of the affordable care act most plans are non-grandfathered so this rule would apply to most individual and group private health insurance plans the rule also says that during the public health emergency for covid19 the plans and issuers must offer this qualifying chronovirus preventative service with no cost sharing regardless of whether an in-network or out-of-network provider is delivering

the server so it clears up that network distinction that some people might be concerned about let's talk about medicaid coverage coming out of cms for this uh interim final rule states that get enhanced fmap or that federal matching money if you got that enhanced schedule matching money that was authorized by the family's first coronavirus response act you have to meet certain conditions to keep getting that enhanced federal money one of them is that you cover covid vaccines and administration

so this would be uh something that applies to most medicaid beneficiaries without cost sharing there are some people that are enrolled in what is considered to be a limited benefit medicaid plan like tb related medicaid or family planning only services this doesn't necessarily apply to the limited medicaid benefit programs for those individuals you might consider coverage that comes through the coveted claims reimbursement program that same program available for people that are considered to be uninsured it's how

hospitals would seek reimbursement for the vaccine so let's do a quick recap by coverage type medicare if you have medicare this interim final rule says there would be no cost for covid vaccines and copayments co-insurance and deductibles would be waived same is true for medicare advantage plans for medicaid state medicaid and ship agencies the children's health insurance program agencies must provide vaccine administration with no cost sharing for most beneficiaries during the public

health emergency for private plans this is the centers for medicare and medicaid services the department of labor and the department of treasury coming together requiring that most private health plans and issuers cover a recommended coven 19 vaccine and its administration both in network and out of network with no cost sharing and finally if you are uninsured providers will be able to be reimbursed for administering the vaccine to individuals without health insurance and that's administered

through the health resources and services administration that might sound familiar that's the same setup that's that same program for people that are being uh that providers that are providing covet testing to people that don't have insurance now timing like we said there's no vaccine available right now in a question and answer session with the journal of the american medical association dr fauci predicted we won't see any fda approved vaccines until 2021 he actually said fda authorization could come in january

or it could be later he's trying to manage our expectations we he said we're going to need to see safety data we're going to need to see prolonged efficacy data but again centers for medicare and medicaid services are starting to do the paperwork and planning for the coverage considerations should that vaccine happen anytime in early 2021 or later in the description below we have a lot of resources for you first of all that press release that comes out of cms they also produced a fact sheet there are a lot of coverage systems and payers

that they're trying to keep straight the fact sheet helps sort through that the interim final rule like we said it'll appear in the federal register there is a public comment period that runs for 30 days we share information on that should you wish to comment or read the rule the covet vaccine resources for providers health plans and medicaid programs that toolkit we mentioned before we also link to that in the description below if you want to read more about dr fauci's comments to jama in his question and answer we also share that interview

in the description below