COVID-19 Vaccines and Coverage

The Food and Drug Administration (FDA) awarded an Emergency Use Authorization (EUA) to three companies for their vaccines: Pfizer on Dec. 11, 2020, Moderna on Dec. 18, 2020, and Janssen Pharmaceutical Companies of Johnson and Johnson on Feb. 27, 2021. On Aug. 23, 2021, the FDA granted full approval of the Pfizer COVID-19 vaccine for ages 16 and older. The Pfizer vaccine, known as Comirnaty is also available under EUA for ages 12-15. See the FDA website for prescribing information.

Booster Shots and Additional Doses: The federal government requires us to cover the COVID-19 vaccine at no cost share through the end of the public health emergency (PHE). This includes COVID-19 booster shots and additional doses. The CDC provides guidance on the administration of the vaccine. At the end of the PHE, we will provide updates on our coverage.

Initially, the federal government will pay for the vaccine . Blue Cross and Blue Shield of Texas, or self-funded groups, will cover administration of the vaccine as noted below. The administration of additional doses and boosters will be covered in the same way as the original doses of the vaccine during the PHE:

Fully insured:

• Vaccine and administration covered as a preventive service with no cost-share to members at in-network providers.
• Vaccine and administration covered with no cost-share to members if delivered at out-of-network providers through the end of the public health emergency.

Self-funded employer groups:

• Non-grandfathered self-funded employer groups - vaccine and administration covered as a preventive service with no cost-share to members at in-network providers.
• Vaccine and administration covered at no cost-share to members at out-of-network providers through the end of the public health emergency.
• Self-funded employer groups that don’t cover preventive vaccines through their pharmacy benefit must cover the vaccine through their medical benefit.
• Grandfathered plans are not required to cover preventive services, including the COVID-19 vaccine.

Medicare Advantage and Medicare Supplement

• For 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration will be through the original fee-for-service Medicare program.
• Submit claims for administering the COVID-19 vaccine to the CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved.
• Members will have no cost-sharing on vaccines through Dec. 31, 2021.

Medicaid

• Most Medicaid members will have no cost-sharing on vaccines from in- and out-of-network providers. See the CMS Medicaid toolkit for more details.

Reimbursement:

• In-network providers will be reimbursed for the administration fee based on contracted rates.
• Out-of-network providers will be reimbursed based on established OON reimbursement policy that follows Medicare rates.

Balance billing: Providers are prohibited from billing patients for the vaccine or its administration, including balance billing, if the provider received the vaccine at no cost from the government.

Coding claims: CMS and the American Medical Association (AMA) have identified the codes to use in submitting claims. For more information, see CMS’ guidance.

When billing a vaccine administration code with an office visit, if the vaccine is not the primary purpose of the office visit, bill the vaccine on a separate claim.

Dosage: Candidate vaccines may require one or two doses. The Pfizer and Moderna vaccines require two doses. The Janssen/Johnson & Johnson vaccine is one dose. Guidance on additional doses is evolving. Follow CDC guidelines .

More information:

• CDC COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations
• Provider Relief Fund – for reimbursement for administering the COVID-19 vaccine to the uninsured
• CMS Medicaid Toolkit - Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Children’s Health Insurance Program, and Basic Health Program
• CMS guidance on Medicare billing for the COVid-19 vaccine administration

We continue to monitor information provided by the CDC and other government and health officials. We’ll provide updates when we have them. For the latest information on COVID-19, we recommend visiting the CDC’s COVID-19 website .

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