In most cases, Americans will not pay anything for a COVID-19 vaccine. Government officials know that cost is often a barrier to access to health care, so laws and regulations were implemented soon after the pandemic began to ensure free access to vaccines for most people.
Because U.S. health insurance coverage is far from uniform, it’s important to know and understand the specifics of your plan. During the public health emergency (currently valid until October 20, 2021), most people will have access to a zero-cost COVID-19 vaccine.
Assuming the public still needs regular COVID-19 vaccinations, coverage details may change once the COVID-19 public health emergency is over.
In the case of COVID-19, it is well known that advanced age is an important risk factor for serious complications. Fortunately, nearly all Americans 65 and older have Medicare, and the government has ensured that the COVID-19 vaccine is free for Medicare beneficiaries.
COVID-19 Vaccines: Stay up to date on vaccines that are available, who can get them, and how safe they are.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted in March 2020, covers health insurance coverage for the COVID-19 vaccine.
Under the law and a subsequent interim final ruling issued in November 2020, Medicare beneficiaries are not required to pay anything for the COVID-19 vaccine or its administration. This is true whether they have Original Medicare, Medicare Advantage, or Medicare Premium.
The implementation of these differs only slightly:
- Original Medicare: The COVID-19 vaccine is covered by Medicare Part B, just like the flu and pneumococcal vaccines, waiving the normal Part B deductible.
- Medicare Advantage: Medicare Advantage plans cover all the same services provided by Original Medicare (Parts A and B), but they can have different cost-sharing amounts. However, for the COVID-19 vaccine, the interim final rule makes clear that the private health insurance advantage cannot impose any cost-sharing on the vaccine or its administration.
- Medicare Fee Plans: Original Medicare and Medicare Advantage plans are covered directly in the CARES Act, but Medicare Fee Plans are not. However, under the interim final rule, the Medicare fee plan must provide coverage for the COVID-19 vaccine at no cost until the current public health emergency ends.
The CARES Act stipulates that Medicare coverage begins the same day a vaccine is approved by the Food and Drug Administration (FDA). Under the Public Health Service Act, any Emergency Use Authorization (EUA) granted by the FDA will be considered a license during a public health emergency.
That means any COVID-19 vaccine that receives FDA emergency use authorization will be fully covered by Medicare on day one.
The FDA granted the first EUA for the Pfizer-BioNTech COVID-19 vaccine on December 11, 2020. The Moderna vaccine received an EUA the following week. Johnson & Johnson’s first single-dose COVID-19 vaccine received EUA designation on February 27, 2021.
On August 23, 2021, the FDA fully approved the Pfizer-BioNTech COVID-19 vaccine for use in individuals 16 years of age and older. Five months later, Moderna’s vaccine was fully approved for adults 18 and older.
How does Moderna’s vaccine stack up against Pfizer’s?
private health insurance
More than half of Americans have private health insurance through their employer or the personal marketplace (exchange or over-the-counter). Most of these cover the COVID-19 vaccine without any cost-sharing, but there are exceptions.
The CARES Act requires full coverage of COVID-19 vaccinations for most people with private health insurance. This applies to all non-grandfathered primary medical plans in the individual/family market and group (employer-sponsored) market.
Under the CARES Act, non-grandfathered individuals and employer-sponsored plans must cover COVID-19 vaccines, including any cost of vaccination, without cost-sharing.
This benefit is under the preventive care guidelines of the Affordable Care Act (ACA) and will continue even after the public health emergency ends.
Under normal circumstances, mandatory preventive health care benefits will only take effect about a year after a recommendation is issued by the U.S. Preventive Services Task Force (USPSTF) or the Advisory Committee on Immunization Practices (ACIP).
Under the CARES Act, this process is expedited. No more than 15 business days after the USPSTF or ACIP recommendation is issued, non-grandfathered plans are required to add COVID-19 vaccinations to their statutory benefits instead of one year (or two years in some cases).
This means that, for most people with private insurance, coverage will start the moment a vaccine becomes available (considering the lag time between the issuance of the advice and the distribution of the vaccine). If in doubt, call your insurance company.
The interim final rule also states that private insurance plans must waive all cost-sharing, even if providers bill vaccine costs and administrative costs separately. This applies even if the member receives the vaccine from an out-of-network provider.
Does my plan cover the COVID-19 vaccination?
CARES Act does no Apply to grandfather health plan. These were plans purchased on or before March 23, 2010, and represent approximately 14% of all employer-sponsored health plans in the United States.
For these plans, there is no cost-sharing for COVID-19 testing during a public health emergency under the Families First Coronavirus Response Act.what is possible no What is covered is the cost of the vaccine or its administration.
Grandfather’s health plan has a different approach to this shortcoming. In some cases, state governments may step in and require some or all of these programs to forgo cost-sharing.
In other cases, the plan may voluntarily agree to do so. This is most likely related to employer-sponsored programs, as employers will directly benefit from keeping employees healthy and free from COVID-19.
Programs not regulated by the ACA
Vaccine coverage requirements do not apply to plans not regulated by the ACA. These include:
- short-term health plan
- fixed compensation plan
- Health Care Shared Ministry Program
- Farm Bureau Programs Explicitly Excluded from Insurance Laws and Regulations
At least 3 million Americans are enrolled in short-term health programs, and 1.5 million are enrolled in shared health care programs.
While some insurers not regulated by the ACA may agree to voluntarily include COVID-19 vaccinations into their benefits, be aware that they may or may not waive cost-sharing entirely.
One such example is Liberty HealthShare, one of the most popular health care sharing ministry plans, which has said vaccine costs will be shareable. Other ministry plans have done the same, sometimes requiring members to reach their normal “annual unshared amount” (similar to a health insurance deductible) before sharing the cost of vaccines.
If you are covered by any of these plans, contact the company to find out if and how they will pay for the COVID-19 vaccination.
Grandmothers and Self-Insurance Plans
The requirement for zero cost-sharing of the COVID-19 vaccine does apply to the grandmother (transition) plan and the non-grandfather self-insurance plan, both of which are already required to cover preventive services under the ACA.
What happens when the COVID-19 cost-sharing waiver ends?
Under the Families First Coronavirus Response Act, states are eligible for additional Medicaid funding during the COVID-19 public health emergency as long as they meet a few basic requirements. This includes ensuring beneficiaries have zero-cost-sharing coverage for COVID-19 testing, treatment and vaccines.
Right now, all states are getting additional federal funding so nearly all Medicaid recipients can get a zero-cost COVID vaccine.
But COVID-19 vaccine coverage requirements do not extend to limited benefit Medicaid programs, such as those that provide Medicaid coverage only for family planning services or TB-related services.
After the COVID-19 public health emergency is over, Medicaid coverage may vary by person’s eligibility category. Even so, most enrollees will likely get a zero-cost COVID-19 vaccine. This includes children and adults eligible for the ACA Expanded Medicaid program.
States have the option to continue to provide these groups with zero-cost coverage of the COVID-19 vaccine, but under current rules, this is not required.
Potential Medicaid Enrollee no Benefits include those who qualify because of pregnancy, disability, or being the parent/carer of a minor child.
Children’s Health Insurance Plan (CHIP)
Children’s Health Insurance Plan (CHIP) coverage is authorized to cover all ACIP-recommended vaccines for children under the age of 19, with zero cost-sharing.
Therefore, once a COVID-19 vaccine is recommended by ACIP, it will be fully covered by CHIP. That being said, it’s only available for the recommended age group. Currently, Pfizer’s vaccine recommendations are only for people 12 years of age and older, while Moderna’s and J&J’s vaccines are only approved for people 18 and older. That could change based on current vaccine trials in children.
In addition to children, some states offer CHIP coverage for pregnant women and choose to offer zero-cost sharing of recommended vaccines as part of that coverage.
basic health plan
Essential health plans are currently in effect in Minnesota and New York. These plans provide affordable health coverage to people with incomes up to 200% of the Federal Poverty Level (FPL) with fairly low out-of-pocket costs.
These state-funded programs must provide coverage for ACA’s Essential Health Benefit (EHB), including zero-cost-sharing preventive care.
The interim final rule further stipulates that essential health plans must fully cover these costs, whether vaccines are administered by in-network or out-of-network providers.
What to do if you are charged for a COVID test
For most people, the limiting factor for COVID-19 vaccination is not health coverage, but vaccine availability. Once it’s your turn, your health insurance will almost certainly pay for your vaccinations, no matter where you are.
If you are uninsured or have a health plan without such benefits, you may still be eligible for free vaccinations through a federal program created to help uninsured Americans.
Frequently Asked Questions
How much is the uninsured COVID-19 vaccine?
The COVID-19 vaccine is free for anyone in the United States. If you are uninsured, the Department of Health and Human Services recommends that you call your provider to confirm that they agree to enroll in the Health Resources and Services Administration (HRSA) Uninsured Plan. Through the program, providers bill the government for vaccinations.
Why do I have to bring my insurance card to get the COVID-19 vaccine?
Even with free vaccinations, your healthcare provider can claim reimbursement from your insurance company for the cost of vaccinations. You won’t get a bill because they can’t charge you the balance.
Can you get the COVID-19 vaccine if you are undocumented?