How 6 Patient Populations Receive Coronavirus Vaccine Coverage

Medicare beneficiaries

The Medicare patient population is 60 million strong and includes both anyone 65 years and older and adults under age 65 with certain debilitating conditions.

Vaccines may be covered under either Medicare Part B or Medicare Part D. The influenza vaccine and a handful of other vaccines are available through Part B along with any vaccines needed to prevent diseases or injuries that Part B covers. The remaining vaccines are covered under Part D.

The coronavirus vaccine will be covered under Part B. Beneficiaries face zero cost-sharing, regardless of whether the vaccine was authorized through the Federal Drug Administration or a Biologics License Application.

“Covering a COVID-19 vaccine under Part B rather than Part D will ensure broader coverage for the vaccine under Medicare since not all beneficiaries are enrolled in a Part D plan,” the researchers expounded.

Medicare reimbursement will occur at 95 percent of the average wholesale price.

Private payer members

Private payer vaccination policies will apply to all American adults with employer-sponsored health plans or ACA-compliant plans on the individual health insurance market. In 2019, that population encompassed around 55 percent of Americans but the industry has seen significant shifts in this sector, at least in part due to the coronavirus pandemic.

The Coronavirus Aid Relief, and Economic Security (CARES) Act mandated that private payers must cover the vaccine 15 days after the CDC’s Advisory Committee on Immunization Practices recommends the drug.

“This will ensure that a coronavirus vaccine is covered by private insurance more quickly than the longer timeframe typically required for private health plans to incorporate a new ACIP recommendation,” the researchers added.

Private payers must cover the vaccine with zero cost-sharing for members for the duration of the public health emergency, including in cases when an out-of-network provider delivers the vaccine. The rule also outlaws balance billing or extracting any other form of payment from vaccinated patients.

Payers may hope that these restrictions prevent the vaccination process from experiencing the same challenges that the coronavirus testing process has faced.

However, if the Supreme Court overturns the Affordable Care Act, this mandate would no longer have the force of law.

Vaccines for Children program eligible patients

More than half of all young children and a third of all adolescents are eligible for the Vaccines for Children program, according to HHS. Eligibility requirements include uninsurance, Medicaid eligibility, and being either an American Indian or Alaska Native.

In this program, the CDC buys and distributes vaccines to state health departments and health agencies. Eligible children receive these vaccines for free, though they may need to pay the provider for the vaccine administration or the visit.

Coronavirus vaccination policies for this patient population remains vague.

First, the FDA has not yet approved a vaccine for children.

Moreover, the CDC has not yet made a decision on how these enrollees will receive vaccine coverage, as of mid-November 2020.

Medicaid, CHIP beneficiaries

75.5 million Americans receive coverage under Medicaid or the Children’s Health Insurance Program (CHIP).

Medicaid’s general vaccine coverage is not uniform and, thus, neither is Medicaid’s coronavirus vaccination coverage.

The Families First Coronavirus Response Act (FFCRA) made free coronavirus vaccination a requirement in order for states to receive a Medicaid federal funding boost. As of November 2020, all states have chosen to comply with the requirement to receive the extra funding.

Coverage, in this case, includes the vaccine administration fee or the office visit fee.

These mandates will terminate with the public health emergency, however. Once the public health emergency expires, Medicaid beneficiaries will be subject to the typical Medicaid vaccination rules for coronavirus vaccination coverage.

For children in CHIP, coverage for age-appropriate vaccines using CHIP funding is required.

“Medicaid coverage for vaccines varies based on age, eligibility pathway, and state,” the brief stated. “Vaccines are an optional benefit for certain adult populations, including low-income parent/caretakers, pregnant women, and persons who are eligible based on old age or a disability. For adults enrolled under the ACA’s Medicaid expansion and other populations for whom the state elects to provide an “alternative benefit plan,” their benefits are subject to certain requirements in the ACA, including coverage of ACIP-recommended vaccines with no cost sharing.”

Uninsured adults

Unlike children, uninsured adults do not have a vaccination coverage program. However, they do have some options for receiving vaccination coverage.

“Providers that participate in the CDC COVID-19 Vaccination Program contractually agree to administer a COVID-19 vaccine regardless of an individual’s ability to pay and regardless of their coverage status,” the brief explained. ‘Providers that administer the COVID-19 vaccine to the uninsured will be reimbursed for vaccine administration costs through the $175 billion provider relief fund created by the CARES Act.”

The fund has dwindled down to $30 billion, as of early November 2020. Additional funding will be necessary to distribute the coronavirus vaccine and to educate the uninsured population about its availability.

Veterans

There are 6 million patients who receive coverage from the Veterans Health Administration (VHA).

Veterans do not have to pay for any outpatient visit that involves vaccinations. However, the VHA has not issued any requirements around coronavirus vaccine coverage.

“The federal government has already paid for several hundred million doses of multiple COVID-19 vaccines through Operation Warp Speed, even before clinical trials have been completed,” the researchers stated.

“If concerns arise about the eventual cost of COVID-19 vaccine(s) or other vaccines to federal and state governments and private payers, policymakers may look to rules that already govern vaccine pricing and reimbursement in different markets to leverage the government’s buying power.”

However, payers have indicated that it is not providing coronavirus vaccine coverage that places as their top concern, but rather whether the vaccine will work.