When Americans receive a coronavirus vaccine, federal rules say they shouldn’t have to pay anything out of pocket.
Congress passed legislation this spring that bars insurers from applying any cost sharing, such as a co-payment or deductible. It layered on additional protections barring pharmacies, doctors and hospitals from billing patients.
To consumer advocates, the rules seem nearly ironclad — yet they still fear that surprise vaccine bills will find their way to patients, just as they did with coronavirus testing and treatment earlier this year.
“It is the American health care system, so there are bound to be loopholes we can’t anticipate right now,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.
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Americans vaccinated this year and next generally will not pay for the vaccine itself, because the federal government has purchased hundreds of millions of doses on patients’ behalf. It has agreed to buy 100 million doses from Pfizer-BioNTech — and is in negotiations for more — and 200 million from Moderna, enough to inoculate 150 million Americans (the vaccines require two shots). It also has orders in to purchase more vaccines still undergoing trials.
The Affordable Care Act provides additional protections, because it requires most health insurers to fully cover all federally recommended preventive care. The CARES Act, passed this spring, supercharged these Obamacare rules.
Usually, insurers have about two years to start covering a newly approved preventive service. The CARES Act required coverage 15 days after a recommendation from the federal Advisory Committee on Immunization Practices.
Some insurers, including Aetna and certain Blue Cross Blue Shield plans, have already announced that they will not bill patients for the vaccine or its administration.
“Health insurance providers pay for the administrative fees associated with administering the Covid-19 vaccine,” said David Allen, a spokesman for America’s Health Insurance Plans. “The administration fee covers clinicians providing the vaccine to patients, public health reporting, and addressing patient questions.”
The federal government has used other levers to curtail surprise vaccine bills. When it offered enhanced Medicaid payment rates this spring, it required states to fully cover coronavirus vaccines for all their enrollees as a condition of receipt. All 50 states accepted the extra funding, and are now subject to those requirements.
Elsewhere, the Centers for Disease Control and Prevention requires vaccine providers to sign a contract agreeing not to bill patients for the vaccine and the cost of administering it. Out-of-network doctors who do not have a contract with a patient’s private insurance will be required to accept the Medicare rate for administering the vaccine — $16.94 for the first dose and $28.39 for the second, according to rules published in October. For uninsured patients, health providers will need to send those charges to a provider relief fund for reimbursement.
That’s different from the rules around coronavirus treatment, which regulated insurers’ cost sharing but did not take steps to curtail billing by doctors and hospitals. That meant some patients received bills they didn’t expect.
“What makes the vaccine protections unique is that there are requirements on both the insurers and the providers,” said Karyn Schwartz, a senior fellow at the Kaiser Family Foundation. “It’s a belt-and-suspenders approach that makes the consumer protections much stronger.”
Even with these protections, experts do see some weak spots. One has to do with the type of health coverage Americans carry. Millions are still covered by “grandfathered” health insurance plans, which existed before the Affordable Care Act and are exempt from its rules. So those plans are not required to fully cover the coronavirus vaccine, or any other preventive service.
Experts also worry about uninsured Americans. The United States does not have a national program to cover vaccination costs for them. For coronavirus, it is instructing health providers to submit costs associated with vaccination to a $175 billion Provider Relief Fund created last spring.
The fund had $30 billion remaining as of Nov. 10. There’s no backup source of funding for the uninsured to get covered if it’s depleted.
“The question marks for me are the uninsured, and the folks that are in the unregulated plans,” Ms. Corlette said.
Additional fees could accompany a vaccine. Some providers are accustomed to charging a visit fee for all in-person patients. Most emergency rooms charge “facility fees,” the price of coming in the door and seeking care, as do some hospital-based doctors. Some patients receiving coronavirus tests at emergency rooms faced facility fees higher than $1,000, according to billing documents submitted to The New York Times. These fees typically do not exist at retail pharmacies, where many Americans may get vaccinations.
Federal law is quite clear that patients should not have to pay for the vaccine and its administration. But there isn’t language that defines what counts as “vaccine administration,” and whether the visit fee makes the cut.
“The question that I’m still not clear on is what happens if someone walks into an outpatient department that charges a facility fee and gets a vaccine,” said Kao-Ping Chua, an assistant professor of pediatrics at the University of Michigan who has studied coronavirus medical billing. “Is there a possibility they could get charged? I think the answer is yes.”
If patients have adverse reactions to the vaccine and require medical care — as one health care worker in Alaska did earlier this week — they will not have special protections against those charges. If a visit for a vaccine delves into other medical issues — if a patient, for example, also has blood drawn or discusses pre-existing conditions with a provider — that could also mean regular fees for care.
Then there is the prospect of Obamacare repeal. Last month the Supreme Court heard oral arguments in a case aiming to end the Affordable Care Act. If the challenge is successful, it will invalidate the Obamacare mandate to cover preventive services like the coronavirus vaccine.
Insurers may still choose to cover the vaccine — and find it cost-effective to do so, if it prevents hospitalizations — but they could charge a co-payment, just as they do for doctor’s visits and prescription drugs.
“All the vaccine coverage hinges on the Affordable Care Act,” Ms. Corlette said. “So if that goes away, that is another very big problem.”