Each week in recent months it seems like there’s new information to absorb about the novel coronavirus (COVID-19). We’re all learning about the virus as we go and trying to keep up with the related legislation and other public policy.
And as we begin the Affordable Care Act (ACA) annual open enrollment period (Nov. 1 – Dec. 15, 2020 in most states), many people are wondering if their health insurance will cover the COVID-19 vaccine once it’s available.
In the remainder of this post, we’ll cover the following topics in detail:
- When a COVID-19 vaccine may be available – Jun – Aug 2021 for most of us.[0]
- Whether or not your health insurance will cover the COVID-19 vaccine – Yes but only if you have an ACA health plan, others may not include coverage.[1]
- How much a COVID-19 vaccine might cost if you’re uninsured – Around $200 per dose.[2]
When will the COVID-19 Vaccine be Available?
Dr. Anthony Fauci, the U.S.’s top infectious disease expert, expects to be able to identify a safe and effective vaccine by November or December 2020.[3]
However, that doesn’t mean that’s when the vaccine will be available to the majority of the U.S. population.
With a complex supply chain; significant challenges to overcome for storing, handling and administering the doses; and an immunization priority order (e.g, vaccinating frontline healthcare providers, first responders, and people at a higher risk for severe disease first), the average American likely won’t have access to the vaccine until sometime in 2021.[4]
In September (2020), the CDC Director, Dr. Robert Redfield, essentially agreed with this predicted timeframe when he indicated that the U.S. would have enough coronavirus vaccine to return to what he referred to as “regular life” by the third quarter of 2021.[5]
Will ACA Health Plans Cover the COVID-19 Vaccine?
The short answer is yes, ACA-regulated individual and group plans will likely cover the COVID-19 vaccine once it is available.[6]
That includes the following types of plans:[7]
- Individual plans purchased on the ACA Exchange (healthcare.gov or your state’s ACA enrollment website)
- Individual major medical plans purchased away from the Exchange (i.e., directly from an insurance company)
- Employer’s qualifying group health plan
Language included in the March 2020 Coronavirus Aid, Relief, and Economic Security (CARES) Act requires insurers to add coverage for the COVID-19 vaccine to their ACA health plans within 15 days of the vaccine being recommended for inclusion on the ACA’s list of “immunizations for routine use” by ACIP (Advisory Committee on Immunization Practices).[8]
Do you want to find plans that include coverage for the COVID-19 vaccine, as well as testing and treatment?
Coverage on other “Qualifying” Health Plans
Even though Medicare, Medicaid, and CHIP are considered “qualifying” health plans under the ACA, they don’t all follow the same guidelines as individual and group ACA health plans.
For example, Medicare has separate rules about which immunizations are covered and which are subject to cost-sharing.
Here is what we know today about COVID-19 vaccine coverage on these plans.
Medicare: The CARES Act requires traditional Medicare and Medicare Advantage plans to cover COVID-19 vaccinations after the Federal Drug Administration (FDA) licenses it for use, prior to the formal CDC general use recommendation.[9]
Medicaid: Coverage for adult immunizations for those enrolled in traditional Medicaid is determined at the state level. Adults enrolled in ACA-expansion Medicaid follow the same vaccine guidelines as ACA health plans described above.[10]
If you use the Vaccines for Children (VFC) program along with Medicaid, you may be charged an administrative fee.[11]
CHIP: Children enrolled in separate CHIP plans are covered for all government-recommended vaccines, which would include COVID-19 once it’s approved for routine use.[12]
Will Non-ACA Qualifying Health Plans Cover the COVID-19 Vaccine?
For any insurance plans that do not follow the ACA’s guidelines, like short term health insurance, it will be up to individual insurers to determine if they want to include coverage for the COVID-19 vaccine.[13]
Since many non-ACA plans already don’t include coverage for vaccinations, it seems unlikely that insurers will opt to cover the costs of the COVID-19 vaccine.
What Will The COVID-19 Vaccine Cost?
The new COVID-19 vaccine should come with no additional out-of-pocket costs as part of your ACA plan’s preventive health benefits.
Today, ACA health plans are required to include the ACIP-recommended “immunizations for routine use” as preventive care and are available without having to pay coinsurance or copayment even if you haven’t yet met your annual deductible.[14]
The coronavirus vaccine would be covered the same way the annual influenza vaccination, measles, mumps, or tetanus boosters are, as one of the services covered under the ACA’s essential health benefits.[15]
In addition, the CARES Act requires COVID-19 immunizations as approved for emergency use to be free as well.[16]
Other qualifying plans like Medicare, Medicaid, and CHIP may have different guidelines relating to fees and cost-sharing. And if you don’t have ACA coverage, there’s a chance you’ll have to pay fully out of pocket for the cost of the COVID-19 vaccine unless additional legislation is passed to provide more access.
Getting the COVID-19 Vaccine if You’re Uninsured
The CARES Act included explicit language that added COVID-19 vaccine coverage to ACA health plans. But it did not address coverage relating specifically to those with Medicaid or anyone without insurance, leaving some significant vaccine accessibility gaps.
The HEROES Act (Health and Economic Recovery Omnibus Emergency Solutions) which passed the U.S. House in May 2020, but has not passed out of the U.S. Senate as of October 2020, was slated to fill some of those gaps.
The HEROES Act would:
- Amend both the VFC and CHIP to cover the COVID-19 vaccine without cost-sharing[17]
- Classify COVID-19 as a mandatory Medicaid benefit regardless of whether you qualified via traditional or expanded ACA, and make immunization coverage mandatory for all adults instead of leaving it for states to decide[18]
- Extend the existing state option originally outlined in the Families First Coronavirus Response Act[19] to cover uninsured individuals not just for testing and treatment but also for the COVID-19 vaccine[20]
Unfortunately, those without any form of ACA-qualifying coverage will likely have to pay the full cost of the COVID-19 vaccine on their own.
How Much Will the COVID-19 Vaccine Cost Without Health Insurance?
While it’s still too early to accurately predict what a COVID-19 vaccine (or series of shots as may be needed) will cost, for comparison, Pfizer’s pneumococcal pneumonia vaccine (another respiratory-virus vaccine) costs $200 for each of the four doses that comprise the full course.[21]
Though pharmaceutical companies are pledging they won’t inflate the COVID-19 vaccine price in order to make a profit off of a public health emergency, there are currently no formal controls or price caps in place. They can ultimately charge whatever they want, and none of the companies with a COVID-19 vaccine in development have promised to make the vaccine available at cost.[22]
It should be noted that U.S. taxpayers have already made a substantial investment in the COVID-19 vaccine, with the federal government allocating more than $9 billion in funds to private pharmaceutical companies to expedite development of vaccine candidates, and another $2.5 billion for storage, delivery, and manufacturing of the vaccine once a viable candidate has been identified.[23]
Summary + Next Steps
We discussed a lot of information relating to the future COVID-19 vaccine, including when it may become available, whether or not health insurance will cover it, and how much it could cost out-of-pocket.
For now, if you want to obtain health insurance that covers the COVID-19 vaccine if you don’t have comprehensive health benefits through your employer, an individual ACA health insurance plan, purchased either on healthcare.gov or your state’s ACA Marketplace is likely your best option.
Remember, ACA plans can only be purchased during annual open enrollment or a special enrollment period if you qualify.
It remains to be seen whether federal lawmakers will pass additional COVID-19 legislation such as the U.S. House approved HEROES Act, and if that will expand access to the vaccine to more people.
If you have questions or want individual help understanding your health insurance options, agents are available to help, call (888) 855-6837.
