Immunocompromised Enrollees in Medicaid, CHIP, and Most Group Health Plans and Health Insurance Coverage May be Able to Receive an Additional COVID-19 Dose at No Cost
In response to the Food and Drug Administration’s (FDA) and the Centers for Disease Control and Prevention’s (CDC) recent actions that authorize an additional dose of COVID-19 vaccine for immunocompromised individuals, the Centers for Medicare & Medicaid Services (CMS) is assuring those enrolled in Medicaid, the Children’s Health Insurance Program (CHIP) and most group health plans and health insurance coverage who qualify for this additional dose that they can receive it for free. This is part of President Biden’s commitment that consumers have access to the necessary vaccinations to protect themselves and others from COVID-19 with no additional costs. In addition, following up on last week’s news alert, CMS has released guidance about billing and coding for the additional dose of certain COVID-19 vaccines for certain immunocompromised Medicare patients.
Medicaid: State Medicaid and Children’s Health Insurance Program (CHIP) agencies must cover COVID-19 vaccine administration with no cost sharing for nearly all enrollees during the COVID-19 public health emergency (PHE) and for over a year after it ends. This coverage would also include the administration of an additional vaccine dose for those who are immunocompromised. CMS is providing information and resources to states on coverage of COVID-19 vaccine administration with no cost sharing for enrollees who are immunocompromised.
Private Insurance: The COVID-19 vaccine is free for people enrolled in most private health plans. The COVID-19 vaccines and the administration are covered without cost sharing for most enrollees, and such coverage must be provided both in-network and out-of-network during the Public Health Emergency. Current regulations provide that out-of-network rates for COVID-19 vaccine administration must be reasonable as compared to prevailing market rates, and the rules reference using the Medicare payment rates as a potential guideline for insurance companies.
When individuals get a COVID-19 vaccine, their health care practitioner cannot charge them for an office visit or other fee if the vaccine is the only medical service provided as part of the visit. If individuals get other medical services at the same time they get the COVID-19 vaccine, they may owe a copayment or deductible for those services. If individuals think their provider incorrectly charged them for the COVID-19 vaccine, they can ask their provider for a refund. If individuals think their provider charged them for an office visit or other fee, but the only service they received was a COVID-19 vaccine, they can report their provider to the HHS Office of the Inspector General by calling 1-800-HHS-TIPS or visiting TIPS.HHS.GOV.
For additional information:
- View the CDC Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States
- View the FDA announcement
- Medicare COVID-19 Provider Toolkit
- COVID-19 Vaccine Toolkit for Health Insurance Issuers and Medicare Advantage Plan Payers (PDF)