Will My Health Insurance Cover a COVID Vaccine?
Fact checked by Heather MercerMedically reviewed by Geetika Gupta, MD
In most cases, Americans pay nothing for the COVID-19 vaccine. Government officials know that cost is often an obstacle to obtaining health care, so laws and regulations were implemented soon after the pandemic began to ensure that most people would be able to access the vaccine at no cost.
Even after the federal public health emergency (PHE) ended in May 2023, most people continue to have access to zero-cost COVID vaccines. But since American health insurance coverage is far from uniform, it is important to learn and understand specifics about your plan.
This article will explain what you need to know about health insurance coverage for COVID-19 vaccines.
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Medicare
When it comes to COVID-19, advanced age is known to be a significant risk factor for severe complications. Fortunately, virtually all Americans 65 and over are covered by Medicare, and the government has ensured that Medicare beneficiaries can access COVID-19 vaccines at no cost.
Takeaway
COVID-19 Vaccines: Stay up to date on which vaccines are available, who can get them, and how safe they are.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, enacted in March 2020, addresses Medicare coverage of COVID-19 vaccines.
Under that law and a subsequent interim final ruling issued in November 2020, Medicare beneficiaries do not have to pay anything for the COVID-19 vaccine or its administration. This is true whether they have Original Medicare, a Medicare Advantage plan, or a Medicare cost plan.
The implementation of these vary only slightly:
Original Medicare: COVID-19 vaccines are covered under Medicare Part B without cost sharing, just like influenza and pneumococcal vaccines, with the normal Part B deductible waived.
Medicare Advantage: Medicare Advantage plans cover all of the same services that Original Medicare (Parts A and B) do, but they can have different cost-sharing amounts. For the COVID-19 vaccine, however, the interim final rule clarifies that private Medicare Advantage cannot impose any cost-sharing for the vaccine or its administration. (During the public health emergency, Medicare Advantage beneficiaries could get vaccines out-of-network, but carriers can now require members to stay in-network in order to receive zero-cost vaccines.)
Medicare Cost plans: Original Medicare and Medicare Advantage plans are directly addressed in the CARES Act, but Medicare Cost plans are not, likely because they are being phased out and only available in a handful of states. That said, Medicare Cost plans cover healthcare expenses like vaccines the same way as Original Medicare does.
The CARES Act specifies that Medicare coverage starts the same day that vaccines are licensed by the Food and Drug Administration (FDA). Under the Public Health Service Act, any emergency use authorization (EUA) granted by the FDA was regarded as licensure for the duration of the public health emergency.
Now that the public health emergency has ended, vaccines must have full use authorization in order to be covered. But the two most commonly-used vaccines in the U.S. (Pfizer/BioNTech and Moderna) both have full use authorization.
Takeaway
What this means is that any COVID-19 vaccine granted emergency use authorization by the FDA was covered fully by Medicare on day one of the public health emergency, and continues to be covered if it has received full FDA approval (which is the case for the Moderna, Pfizer, and Novavax COVID vaccines).
Private Health Insurance
More than half of Americans obtain private health insurance through an employer or the individual/family market (either through the exchange or off-exchange). The majority of these cover COVID-19 vaccines without any cost-sharing, although there are exceptions.
The CARES Act mandates comprehensive coverage of COVID-19 vaccination for most people with private health insurance. This applies to all non-grandfathered major medical plans in both the individual/family market and group (employer-sponsored) market. And this requirement did not change with the end of the public health emergency.
Non-Grandfathered Plans
Under the CARES Act, non-grandfathered individual and employer-sponsored plans are required to cover COVID-19 vaccines, including any charges for administration of the vaccine, without cost-sharing.
This benefit is mandated under the preventive care guidelines of the Affordable Care Act (ACA) and remains in effect even though the public health emergency has ended.
Under normal circumstances, mandated preventive care benefits would only go into effect a year or so after a recommendation is issued either by the U.S. Preventive Services Task Force (USPSTF) or the Advisory Committee on Immunization Practices (ACIP).
But due to the CARES Act, the process was sped up. Instead of a year (or, in some cases, two), non-grandfathered plans were required to add COVID-19 vaccination to their mandated benefits no more than 15 business days after the issuance of a USPSTF or ACIP recommendation.
Takeaway
What this means is that, for most people with private insurance, coverage would begin the moment a COVID vaccine becomes available (given the lag time between the issuance of a recommendation and the distribution of the vaccine). If in doubt, call your insurance company.
The interim final rule also specified that private insurance plans must waive all cost-sharing even if a provider bills separately for the cost of the vaccine and the cost of administration. This applied even if the member received the vaccine from an out-of-network provider.
However, now that the public health emergency has ended, people with private health insurance once again need to ensure that they're using in-network providers for their vaccines, in order to receive the shots without any cost-sharing.
Grandfathered Plans
The vaccine coverage requirements in the ACA and the CARES Act do not apply to grandfathered health plans. These are plans purchased on or before March 23, 2010, and as of 2020, accounted for roughly 14% of all employer-sponsored health plans in the United States.
For these plans, COVID-19 testing was covered with no cost-sharing for the duration of the public health emergency under the Families First Coronavirus Response Act.
But the cost of the vaccine or its administration was not required to be covered, and this continues to be the case (grandfathered plans do not have to provide any zero-cost vaccines, for COVID or any other disease).
Although they are not required to cover the full cost of any vaccines, grandfathered plans can voluntarily agree to do so. This is most likely with employer-sponsored plans, since the employer would benefit directly from keeping their staff healthy and safe from COVID-19.
Plans Not Regulated by the ACA
The vaccine coverage requirement does not apply to plans that are not regulated by the ACA. These include:
An estimated 3 million Americans have coverage under short-term health plans, while more than 1.2 million are enrolled in healthcare-sharing ministry plans.
Takeaway
Although some non-ACA-regulated insurers may agree to voluntarily include COVID-19 vaccination in their benefits, be aware that they may or may not fully waive cost-sharing.
Liberty HealthShare, one of the most popular health care sharing ministry plans, and similar to many of the health care sharing ministries, require members to meet their normal "annual unshared amount" (similar to a health insurance deductible) before the vaccine cost is shared.
If you're covered under any of these plans, reach out to the company to see if and how they will cover the cost of a COVID-19 vaccination.
Grandmothered and Self-Insured Plans
The requirement that COVID-19 vaccines be covered with zero cost-sharing does apply to grandmothered (transitional) plans and non-grandfathered self-insured plans, both of which were already required to cover preventive services under the ACA.
But like other types of insurance, these plans can now require members to get their COVID vaccines in-network in order to have zero cost-sharing.
Related: What Happens When COVID-19 Cost-Sharing Waivers End?
Medicaid
Under the Families First Coronavirus Response Act, states were eligible to receive additional Medicaid funding during the COVID-19 public health emergency as long as they comply with several basic requirements. This includes ensuring that beneficiaries have coverage for COVID-19 testing, treatment, and vaccines with zero cost-sharing.
The American Rescue Plan and Inflation Reduction Act ensure that the full coverage of COVID vaccines continues for Medicaid enrollees continues even though the public health emergency has ended. This includes enrollees with limited-benefit Medicaid, such as breast/cervical cancer coverage and family planning coverage.
Children's Health Insurance Program (CHIP)
Children's Health Insurance Program (CHIP) coverage is mandated to cover all ACIP-recommended vaccines for children through age 19 with zero cost-sharing.
So once a COVID-19 vaccine receives ACIP recommendations, it is fully covered under CHIP. With that said, it is only covered for the recommended age groups.
Currently, the Pfizer and Moderna vaccine recommendations include individuals aged 6 months and older. The Novavax vaccine is approved for people 12 years of age and older, and the Johnson & Johnson vaccine is no longer available.
In addition to children, some states also provide CHIP coverage for pregnant women and have opted to provide recommended vaccines with zero cost-sharing as part of that coverage.
Basic Health Programs
Basic Health Programs are currently in effect in Minnesota and New York, and one is expected to be available in Oregon by mid-2024. These programs provide affordable health coverage to people with incomes up to 200% of the federal poverty level (FPL) and offer fairly minimal out-of-pocket costs.
These state-sponsored programs are required to provide coverage for the ACA's essential health benefits (EHBs), including preventive care with zero cost-sharing.
During the public health emergency, Basic Health Programs had to fully cover these costs regardless of whether the vaccine was administered by an in-network or out-of-network provider. Now that the public health emergency has ended, members can be required to use in-network providers in order to receive zero-cost COVID vaccines.
Related: What to Do If You Are Billed for a COVID Test
Summary
Most Americans continue to have access to zero-cost COVID vaccines, although their health plan will likely require them to use in-network providers in order to obtain these vaccines without any cost-sharing.
COVID vaccines do not have to be made available at no cost (or covered at all) by grandfathered health plans or plans that aren't subject to ACA regulation, such as short-term health plans, fixed-indemnity plans, Farm Bureau plans, and health care sharing ministry plans.
But other than those exceptions, all individual/family plans, employer-sponsored plans, Medicare, and Medicaid/CHIP will cover the full cost of recommended COVID vaccines, as long as the member uses in-network medical providers.
A Word From Verywell
For most people, COVID-19 vaccination coverage will continue to be available indefinitely. If the vaccine is recommended each year, you'll be able to obtain it at an in-network pharmacy or medical office without having to pay anything, just the way you can obtain annual flu shots.
If you're uninsured or have a health plan with no such benefit (ie, a grandfathered plan or a plan that isn't regulated by the ACA), you may still be eligible to get a no-cost vaccination through federal programs created to assist uninsured Americans.
Frequently Asked Questions
How much is the COVID-19 vaccine without insurance?
The COVID-19 vaccine is free for anyone in the United States. If you don't have insurance, the Department of Health & Human Services suggests you call your provider to confirm that they agree to participate in the Health Resources and Services Administration (HRSA) Uninsured Program. With this program, providers bill the government for the cost of administering the vaccine.
Why do I have to bring my insurance card to get a COVID-19 vaccine?
Even with a free vaccination, your health provider will seek reimbursement from your insurance company for the cost of administering the vaccination. You won't get a bill because they can't charge you for the balance, assuming you're using an in-network pharmacy or medical office.
Related: Can You Get the COVID-19 Vaccine if You're Undocumented?
The information in this article is current as of the date listed, which means newer information may be available when you read this. For the most recent updates on COVID-19, visit our coronavirus news page.
Read the original article on Verywell Health.
