What Health Plan Sponsors Need to Know About COVID-19 Vaccine Coverage Requirements

COVID-19 Update

Date: December 14, 2020

With the first COVID-19 vaccine approved for use in the United States, health plan sponsors should review the interim final rule the Departments of the Treasury, Health and Human Services, and Labor published on November 6 regarding required health plan coverage of COVID-19 vaccines. The rule requires group health plans to cover the cost of the vaccine and administration costs within 15 business days after either the U.S. Preventive Services Task Force (USPSTF) makes a recommendation to treat the vaccine as preventive care or the director of the Centers for Disease Control and Prevention adopts a recommendation by the Advisory Committee on Immunization Practices (ACIP) to treat the vaccine as preventive care. Below is a summary of what health plan sponsors need to know to prepare for satisfying this coverage requirement.

Plans covered. The rule applies to non-grandfathered group health plans under the Affordable Care Act other than those providing excepted benefits. Although grandfathered group health plans are not subject to the rule, they may elect to cover COVID-19 vaccines and are encouraged to do so by the regulators.

In-network providers. The vaccine and administration costs must be covered with no cost sharing when administered by an in-network provider.

Out-of-network providers. During the COVID-19 public health emergency, the vaccine and administration costs must be covered with no cost sharing when administered by an out-of-network provider, who must be reimbursed a no less than “reasonable” rate (i.e., Medicare payment rate). When the COVID-19 public health emergency ends, group health plans are not required to continue covering vaccines provided by out-of-network providers. The public health emergency is currently set to expire on January 20, 2021, but will likely be extended by the federal agencies.

Administration costs. A group health plan must cover the vaccine administration costs even if the vaccine itself is paid for by a third party (such as the federal government). The Centers for Medicare & Medicaid Services previously announced that the Medicare payment rates for administering the COVID-19 vaccine will be $28.39 for a single-dose vaccine, and $16.94 for the first dose and $28.39 for the second dose for a two-dose vaccine. These rates may be adjusted geographically but will be considered “reasonable” rates for group health plan purposes.

Office visit costs. Although a group health plan must cover the vaccine and administration without cost sharing, the plan may impose cost-sharing on the related office visit if either (i) the vaccine and office visit are billed separately or (ii) the vaccine and office visit are not billed separately and the primary purpose of the visit was for a reason other than administration of the vaccine. If the vaccine and office visit are not billed separately and the primary purpose of the visit was to obtain the vaccine, the group health plan may not impose cost-sharing on the office visit.

Next steps. With the vaccine’s designation as a preventive care service from USPSTF or ACIP expected soon, sponsors of non-grandfathered group health plans should ascertain whether their insurers and third-party administrators are prepared to:

  • cover the vaccine and its administration cost as preventive care within the 15-business-day deadline,
  • cover the vaccine and its administration cost as preventive care whether received from an in-network provider or an out-of-network provider during the COVID-19 public health emergency, and
  • cover the vaccine and its administration cost as preventive care only when received from an in-network provider after the COVID-19 public health emergency ends.

Plan sponsors should also consider communicating with participants about the COVID-19 vaccine coverage provided by their plans.

FOR MORE INFORMATION

For more information, please contact:

Julia Ann Love
216.566.5686
Julia.Love@ThompsonHine.com

Stephen R. Penrod
216.566.5641
Stephen.Penrod@ThompsonHine.com

Leah Singleton
404.407.3652
Leah.Singleton@ThompsonHine.com

or any member of our Employee Benefits & Executive Compensation group.

Additional Resources

We have assembled a firmwide multidisciplinary task force to address clients’ business and legal concerns and needs related to the COVID-19 pandemic. Please see our COVID-19 Task Force page for additional information and resources.

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