COVID VACCINE PAYMENT UPDATE

COVID Vaccine Payment Update

As distribution of the COVID vaccine ramps up for the general public in the coming months, the vaccine will be paid for by the federal government through funding authorized by the Coronavirus Aid, Relief, and Economic Security (CARES) Act during the declared Public Health Emergency.

However, the administration of the vaccine by a provider will be paid for by non-grandfathered plans/insurance policies. Coverage has to be provided for the administration of the vaccine without cost share whether provided in- or out-of-network during the Public Health Emergency.

Some additional points to remember from the COVID-19 Vaccine Interim Final Rule:

  • Providers who receive free supplies of the COVID-19 vaccine from the federal government are prohibited from charging for any upfront costs, so members should not be billed afterward, according to federal guidance.
  • If a provider mistakenly charges a copay or fee for the administration of the vaccine, those who pay at the point of service, or who are billed later, should submit the claim to Trustmark Health Benefits. In these situations, an employer-sponsored plan will reimburse a member for the administration of the vaccine at a predetermined amount.
  • For a provider with whom the plan or issuer does not have a negotiated rate for such service (such as an out-of-network provider), the plan or issuer must reimburse the provider for such service in an amount that is reasonable, as determined in comparison to prevailing market rates for such service. The departments consider the amount of payment to be reasonable, for example, if the plan or issuer pays the provider the amount that would be paid under Medicare for the item or service. Medicare rates for administration of the vaccine are:
    • $28.39 if one dose vaccine
    • For two-dose vaccines: $16.94 for the first one and $28.39 for the second, adjusted for geography
  • The rule applies to both ERISA, and non-ERISA non-federal, non-grandfathered health plans. It does not apply to grandfathered, retiree-only, excepted benefits, healthcare sharing ministries, expatriate health, HRA or other account-based health plans.

Trustmark will post additional updates as they become available.