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Medicare

Private Insurance

Medicaid

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Basic Health Programs

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Next in COVID-19 Vaccine Basics Guide

Even after the federal public health emergency (PHE) ended in May 2023, most people continue to have access to zero-costCOVID-19vaccines.But since American health insurance coverage is quite variable, it is important to learn and understand the specifics of your health insurance plan.

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Older Black man wearing a mask and receiving a vaccine from a medical provider

Stay up-to-date on COVID-19 vaccines:Stay current on which vaccines are available, who can get them, and how safe they are.

Although the Coronavirus Aid, Relief, and Economic Security (CARES) Act, expired on September 30, 2021, Medicare continues to cover the vaccine and its administration without cost sharing.

This is true whether a person has Original Medicare, aMedicare Advantageplan, or a Medicare cost plan.

The implementation of these vary only slightly:

Now that the public health emergency has ended, vaccines must have full use authorization to be covered. But the two most commonly-used vaccines in the U.S. (Pfizer/BioNTech and Moderna) both have full use authorization.

Private Health Insurance

More than half of Americans obtain private health insurance through anemployeror the individual/family market (either through theexchangeoroff-exchange).The majority of these cover COVID-19 vaccines without anycost-sharing, although there are exceptions.

The CARES Act mandated comprehensive coverage of COVID-19 vaccination for most people with private health insurance. This applied to all non-grandfatheredmajor medicalplans in both the individual/family market and group (employer-sponsored) market.This requirement did not change when the CARES Act expired.

Non-Grandfathered Plans

Under the CARES Act, non-grandfathered individual and employer-sponsored plans were required to cover COVID-19 vaccines, including any charges for administration of the vaccine, without cost-sharing.

Thisbenefit is mandatedunder the preventive care guidelines of theAffordable Care Act (ACA)and remains in effect even though the CARES Act expired.

However, due to the CARES Act, the process was sped up. Instead of a year (or sometimes two years), 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.

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.

During the public health emergency, cost-sharing was waived even if anout-of-network providerwas used to get the vaccine. However, this has changed: People with private health insurance now need to ensure that they’re using in-network providers for their vaccines, to receive the shots without any cost-sharing.

Grandfathered Plans

The vaccine coverage requirements in the ACA and the CARES Act donotapply 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 testingwas 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.

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.

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 waivecost-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 ahealth 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-grandfatheredself-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.

Under the Families First Coronavirus Response Act, states were eligible to receive additionalMedicaidfunding during the COVID-19 public health emergency as long as they complied with several basic requirements. This included ensuring that beneficiaries have coverage for COVID-19 testing, treatment, and vaccines with zero cost-sharing.

The American Rescue Plan andInflation Reduction Actensure that the full coverage of COVID vaccines continues for Medicaid enrollees 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 Advisory Committee on Immunization Practices (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.

These state-sponsored programs are required to provide coverage for the ACA’sessential health benefits (EHBs), including preventive care with zero cost-sharing.

Do I Need an Insurance Card?Even with a free vaccination, your healthcare provider will seek reimbursement from your insurance company for the cost of administering the vaccination so they will ask you for your insurance information.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.

Do I Need an Insurance Card?

Even with a free vaccination, your healthcare provider will seek reimbursement from your insurance company for the cost of administering the vaccination so they will ask you for your insurance information.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.

Even with a free vaccination, your healthcare provider will seek reimbursement from your insurance company for the cost of administering the vaccination so they will ask you for your insurance information.

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.

If you’re uninsured or have a health plan with no vaccine coverage, you may still be eligible to get a no-cost vaccination through federal programscreated to assist uninsured Americans.

The Department of Health & Human Services suggests you call a healthcare provider to find out if they 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.

Summary

Most Americans continue to have access to zero-cost COVID vaccines, and vaccination coverage will likely continue to be available indefinitely (like flu vaccines). However, most health insurance plans will likely require you to use in-network providers to obtain these vaccines without any cost-sharing.

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.

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 ourcoronavirus news page.

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19 Sources

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.Congress.gov.H.R.6201 - Families First Coronavirus Response Act.U.S. Department of Health and Human Services.Fact Sheet: End of the COVID-19 public health emergency.Medicare.gov.Coronavirus disease 2019 (COVID-19) vaccine.Internal Revenue Service, Employee Benefits Security Administration, Centers for Medicare and Medicaid Services.Additional policy and regulatory revisions in response to the COVID-19 public health emergency.Fed Regist. 2020;85:71142-71205.U.S. Department of Health and Human Services.Fact Sheet: End of the COVID-19 public health emergency.U.S. Centers for Medicare and Medicaid Services.Other Medicare health plans.U.S. Food and Drug Administration.COVID-19 vaccines.Maragakis L, Kelen GD.Full FDA approval of a COVID-19 vaccine: What you should know. Johns Hopkins Medicine.Kaiser Family Foundation.Health insurance coverage of the total population.Congress.gov.H.R.748—CARES Act.Internal Revenue Service, Employee Benefits Security Administration, Health and Human Services Department.Coverage of certain preventive services under the Affordable Care Act.Fed Regist. 2015;80:41317-41347.Kaiser Family Foundation.2020 employer health benefits survey.Center on Budget and Policy Priorities.Commentary: Growing evidence shows need for stronger rules for short-term health plans.Colorado Division of Insurance.Health Care Sharing Plans and Arrangements in Colorado. October 2023.Kates J, Cox C, Cubanski J, Tolbert J, Pollitz K.Commercialization of COVID-19 vaccines, treatments, and tests: Implications for access and coverage. Kaiser Family Foundation.Center on Budget and Policy Priorities.Coverage for COVID-19 testing, vaccinations, and treatment.Centers for Disease Control and Prevention.Stay up to date with your COVID-19 vaccines.Centers for Disease Control and Prevention.Getting your COVID-19 vaccine.U.S. Department of Health & Human Services.COVID-19 care for uninsured individuals.

Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read oureditorial processto learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

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U.S. Centers for Medicare and Medicaid Services.Other Medicare health plans.

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Center on Budget and Policy Priorities.Coverage for COVID-19 testing, vaccinations, and treatment.

Centers for Disease Control and Prevention.Stay up to date with your COVID-19 vaccines.

Centers for Disease Control and Prevention.Getting your COVID-19 vaccine.

U.S. Department of Health & Human Services.COVID-19 care for uninsured individuals.

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