Federal regulations say that if Americans get a coronavirus vaccine, they shouldn't have to pay for anything out of their own pocket.
Congress passed law this spring banning insurers from applying cost-sharing such as a co-payment or deductible. It consisted of extra safeguards that prevented pharmacies, doctors, and hospitals from charging patients.
For consumer advocates, the rules seem almost ironic – nonetheless, they fear surprise vaccine bills will find their way to patients, just as coronavirus tests and treatments did earlier this year.
"It's the American healthcare system, so inevitably there are loopholes that we can't anticipate right now," said Sabrina Corlette, co-director of the Center for Health Insurance Reforms at Georgetown University.
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Americans who got vaccinated this year and next will generally not pay for the vaccine themselves because the federal government bought hundreds of millions of doses on behalf of patients. It has agreed to buy 100 million doses from Pfizer-BioNTech – and is negotiating for more – and 200 million from Moderna, enough to vaccinate 150 million Americans (the vaccines require two shots). It also has orders to purchase additional vaccines that are still being tested.
The Affordable Care Act provides additional protection as most health insurers are required to fully cover all federally recommended preventive measures. The CARES bill, passed this spring, has tightened these Obamacare rules.
Typically, insurers have around two years to cover a newly approved prevention service. The CARES Act provided coverage for 15 days following a recommendation by the Federal Advisory Board on Immunization Practices.
Some insurers, including Aetna and certain Blue Cross Blue Shield plans, have already announced that they will not charge patients for the vaccine or its administration.
"The health insurance companies pay the administration fees for the administration of the Covid-19 vaccine," said David Allen, a spokesman for the American health insurance plans. "The administration fee covers clinicians who deliver the vaccine to patients, report to the public health and answer patient questions."
The federal government has used other levers to cut the bills for surprise vaccines. When it offered improved Medicaid payment rates this spring, states had to fully cover coronavirus vaccines as a condition of receipt for all of their participants. All 50 states have accepted the additional funding and are now subject to these requirements.
Dec. 17, 2020, 6:13 p.m. ET
Elsewhere, the Centers for Disease Control and Prevention require vaccine providers to sign a contract stating not to charge patients for the vaccine and the cost of giving it. Doctors outside the network who do not have a contract with a patient's private insurance must accept Medicare's rate for administering the vaccine – $ 16.94 for the first dose and $ 28.39 for the second, according to those released in October Regulate. For uninsured patients, healthcare providers must send these fees to a provider assistance fund for reimbursement.
This differs from the rules for coronavirus treatment, which governed cost-sharing by insurers but did not take steps to restrict medical and hospitals billing. This meant that some patients were getting bills they weren't expecting.
"What makes vaccination protection unique is that there are requirements for both insurers and providers," said Karyn Schwartz, Senior Fellow at the Kaiser Family Foundation. "It's a belt-and-suspender approach that makes consumer protection a lot stronger."
Despite this protection, experts see some weak points. It has to do with the type of health insurance Americans have. Millions are still covered by "grandfather" health insurances that existed before and are exempt from the Act on Affordable Care. Therefore, these plans are not required to fully cover the coronavirus vaccine or any other preventive service.
Experts also worry about uninsured Americans. The United States does not have a national program to cover vaccination costs. For coronavirus, healthcare providers are instructed to submit vaccination-related costs to a $ 175 billion Provider Relief Fund set up last spring.
As of November 10, the fund still had $ 30 billion. There is no source of replacement funding for the uninsured that could be covered when exhausted.
"The question marks for me are the uninsured and the people who are in the unregulated plans," Ms. Corlette said.
Additional fees can accompany a vaccine. Some providers are used to charging a visit fee for all personal patients. Most emergency rooms charge "set-up fees," the price of going in the door and finding care, as do some doctors in hospitals. Some patients who received coronavirus tests in emergency rooms faced setup fees in excess of $ 1,000, according to billing records presented to the New York Times. These fees are typically not incurred at retail pharmacies, where many Americans may be vaccinated.
The federal law is very clear that patients do not have to pay for the vaccine and its administration. However, there is no language that defines what qualifies as "vaccine administration" and whether the attendance fee causes the cut.
"The question that I'm still not clear about is what happens when someone walks into an ambulance that charges a facility and receives a vaccine," said Kao-Ping Chua, an assistant professor of pediatrics at the University of Michigan Coronavirus Medical Billing. “Is there any way they could be charged? I think the answer is yes. "
When patients are experiencing vaccine side effects and need medical attention – as a health care worker in Alaska did earlier this week – they have no special protection against those allegations. If a vaccine visit addresses other medical issues – such as having a patient's blood drawn or pre-existing medical conditions discussed with a provider – this can also mean regular fees for care.
Then there is the prospect of Obamacare repeal. Last month the Supreme Court held an oral argument in a case involving the termination of the Affordable Care Act. If the challenge is successful, Obamacare's mandate for prevention services like the coronavirus vaccine will be void.
Insurers can still choose to insure the vaccine – and find it inexpensive if it avoids hospitalization – but they could ask for a co-payment, just as they would with doctor visits and prescription drugs.
"All vaccine coverage depends on the Affordable Care Act," said Ms. Corlette. "If that goes away, that's another very big problem."