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…
Read More: The Vaccines Are Supposed to Be Free. Surprise Bills Could Happen Anyway.