COVID-19 Vaccines And Coverage

Dec. 18, 2020

Updated Dec. 21, 2020

Updated March 11, 2021

In the face of the COVID-19 pandemic, pharmaceutical companies have moved to produce vaccines. The Food and Drug Administration (FDA) has 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 & Johnson on Feb. 27, 2021

Federal and state health officials are working with the medical community to distribute the COVID-19 vaccine.

Initially, the federal government will pay for the vaccine. Blue Cross and Blue Shield of Montana (BCBSMT), or self-funded groups, will cover administration of the vaccine as noted below:

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.

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.