Health Plans Must Cover COVID-19 Vaccine Without Cost Sharing

On Dec. 12, 2020, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended use of Pfizer Inc.’s COVID-19 vaccine for individuals 16 years of age and older. The Food and Drug Administration (FDA) approved the vaccine one day earlier.

The ACIP recommendation triggers the requirement for non-grandfathered group health plans and health insurance issuers to cover the vaccine without cost sharing. Grandfathered plans may choose to cover the vaccine, and could be required to do so under state law or applicable insurance policies.

Coverage of COVID-19 Preventive Care Services

Non-grandfathered group health plans, and health insurance issuers offering group or individual health insurance coverage, must cover coronavirus preventive services, including recommended COVID–19 immunizations, without cost sharing. During the COVID-19 public health emergency, covered services may be provided by in-network or out-of-network providers.

Coverage of these immunizations must be provided, even if not listed for routine use on the CDC’s Immunization Schedules. Plans and issuers subject to Section 2713 of the Public Health Service Act must also cover, without cost sharing, items and services that are integral to the furnishing of recommended preventive services, including immunization administration.

Coverage Effective Date

Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), plans and issuers must cover the vaccine within 15 business days. It is widely understood that coverage of the COVID-19 vaccine must begin no later than Jan. 1, 2021. Plans and carriers may choose to cover the vaccine before this date. As additional forms of the vaccine are approved by the FDA and recommended by ACIP, they will be required to be covered as well.