The CARES Act requires issuers to cover COVID-19 immunizations and their administration at no cost-sharing. The federal rules further provide that issuers must cover the administration of the immunization by any provider enrolled in the CDC COVID-19 Vaccination Program. The rules clarify that coverage is required, without cost-sharing, for the administration of the immunization even if a third party, such as the federal government, pays for the cost of the immunization. For additional guidance, view Insurance Circular Letter No. 16 (2020) here.

Additionally, the federal rules require COVID-19 immunizations and their administration to be covered when provided by out-of-network providers for the duration of the public health emergency for COVID-19. The rule also dictates that reimbursement for out-of-network providers must be made in an amount that is reasonable, as determined by comparison to prevailing market rates.

Providers that participate in the CDC COVID-19 Vaccination Program must agree to administer a COVID-19 immunization regardless of an individual’s ability to pay or health insurance coverage status. Additionally, providers may not seek any reimbursement, including through balance billing, from an immunization recipient.

The vaccine administration code covers both administrative staff services (such as making the appointment, preparing the patient chart, billing for the service, and filing the chart) as well as clinical staff services (such as greeting the patient, taking routine vital signs, obtaining a vaccine history on past reactions and contraindications, presenting a Vaccine Information Sheet and answering routine vaccine questions, preparing and administering the vaccine with chart documentation, and observing for any immediate reaction). Additional reimbursement for an office visit is not covered when the primary and sole purpose of the visit is to administer the COVID vaccine.

Please continue to check back here for further information. MetroPlusHealth will continue to update you as we learn more ourselves. You can also keep up with the latest provider COVID-19 vaccine updates here or on the CDC site here.