Coronavirus (Covid-19) and the vaccine: Who will pay? And how much will the vaccine cost?

Filed Under: Costs, Health plans, Patients

As the coronavirus (Covid-19) vaccine rolls out nationwide, it’s a common question: Who will pay?

As with many other health care cost questions, it might be complicated. Or, it might be really simple.

It seems obvious that the initial round — front-line doctors and nurses, and long-term care facility residents — will be free to recipients. There are various government statements that the vaccine will be free to everyone. But the U.S. health care system has many ways of making “free” into “not free.” Insured people may fare differently from uninsured people. So it’s worth asking, is it free? Always, and for everyone?

Here’s a quick rundown.

‘You should be covered’

“Essentially, on the patient side, you should be covered,” said Sabrina Corlette,  a Georgetown University professor who studies insurance and the health care system.  “You should not have to pay a dime.”

She added: “For individuals with employer based coverage, group coverage, Medicare,  insurance will have to pay for the cost of administering the vaccine or any associated costs with getting the vaccine. That’s on the private insurance side. That is hats off to the A.C.A., because the A.C.A. requires employer-based health plans and individual market health plans to cover preventive services, including vaccines, with zero cost-sharing. So not only is it covered, but you don’t have to pay a deductible or co-payment or anything like that.”

Uninsured people, she said, should also be covered — the federal government made a pot of money called the “provider relief fund” available to cover uninsured individuals for Covid testing and treatment. That money, she said, should also be available for vaccinations — and if there is not enough left, she expects Congress to put some more money into that fund so providers can get reimbursed.

Two other things happened affecting vaccine coverage, Corlette said. First, Congress beefed up protection earlier this year by mandating that insurers had 15 days from the time of a vaccine recommendation to incorporate it into their plans; previously, the timeline was at least a year from recommendation to incorporation. Second, she said, the Trump administration put out an “interim final rule,” basically like an emergency form of rulemaking, expanding coverage to say the vaccine is covered when delivered not only by in-network providers, but also by out-of-network providers.  And “any provider that gets this vaccine is prohibited from balance-billng patients for anything that the insurance company doesn’t cover,” she said. These protections apply only through the duration of the “public health emergency” declared for Covid-19, she noted. “This is not forever, in perpetuity,” she said, though for the time being “you should not get a bill.”

‘Questions without answers’

Susan Null, medical bill advocate at Systemedic, Inc., in New City, N.Y.,  had another perspective. She wrote in an email: “The vaccine is here and with it many questions without answers. It is too soon to tell exactly how this will play out from a payment perspective.  I suspect the vaccine will be covered  without cost to the patient as promised and promoted by the government.  Most likely this will be covered via the patient’s insurance just as other vaccines are covered and paid. I don’t know what the arrangement will be between the government and the insurer, but I assume the insurer will be reimbursed by the government in some way.

“For those without insurance, there will need to be some sort of mechanism in place to cover those costs.  There might be designated places to go for those vaccines and those providers would seek reimbursement from the government.”

On the vaccine, states have made different commitments. Gov. Roy Cooper of North Carolina and Mandy Cohen, secretary of the state Department of Health and Human Services, said patients would pay nothing for the vaccine, North Carolina Health News reported. In Arizona, Gov. Doug Ducey said the vaccine “should be free for anyone who needs it,” The Arizona Republic reported.

In New York, Gov. Andrew Cuomo said “we also have taken steps to ensure no New Yorker will have to pay a penny to get vaccinated,” as reported on his web site. 

O.K., but why are people still questioning?

Will individual patients have to pay?  And why — despite all the assurances — does this question keep coming up?

Think back to testing. Of course, the federal government said all Covid testing and treatment would be covered, too. But there were plenty of exceptions: People whose tests or treatment did not include mention of Covid on the paperwork, so they were processed as non-Covid. People who weren’t insured and didn’t realize that there was a pot of money set aside in federal legislation to cover their testing and treatment. Hospitals and doctors who also didn’t know about this pot of money, or who found it hard to access. We have heard dozens of stories of people who were charged for Covid testing who thought it should have been paid for.

Another wrinkle: Numerous patients reported that the test was free, but they had been charged for an office visit or hospital visit. That could happen here too.

Null wrote: “In terms of ancillary charges (office visits, vaccination administration fees, ER visits) that might not be fully covered, here are my thoughts.  At this point Covid-related visits are being covered along with the test without patient cost share.  I would assume this would continue for the vaccine but until it happens, it is difficult to guarantee.  If a patient goes to their doctor for the vaccine, and they mention anything other than the vaccine as the reason for the visit, in all likelihood that doctor will bill an office visit on top of the vaccine and its administration. If that visit is coded with something other than Covid, it probably won’t be paid in full by the insurer and it will be subject to patient cost sharing.  If it is billed with a Covid-related diagnosis, then it’s possible it will be covered without cost share, but again, time will tell on this.  The same is true if someone goes to the ER.  There could be non-vaccine related costs that would not be covered without patient cost share.

“When Covid testing first started, the insurance companies were not ready for the variety of billing scenarios that arose and claims got denied and paid incorrectly.  The billing guidance kept changing over the course of a few months until most details became finalized.  Hopefully they will have learned from those mistakes and all of this will be or has been planned in advance to avoid all of that confusion and delay in payments.

“Of course there will probably be outliers in this process and this could result in patient expense.  By outliers I mean at some point when more vaccine is available, some providers might buy it themselves and provide vaccinations for a fee.  This is what happened with Covid tests.  There are many places that provide them for free, but if you want an immediate result, or if you don’t want to follow the standard protocol, then there are places you can go and just pay for it  I would assume the same will happen with this, as there will be people who will want to jump in front of the line to get their shots.  If this happens, I would assume there could be cost to the consumer.

“We are learning as we go on this.  The intent is for there to be no cost for the vaccine to the patient.  The issue is that medical billing is not that straight-forward.  There are any number of scenarios that might arise in which there could be cost to the patient.”

Who might want to pay?

Will there be cases in which organizations can buy vaccine, the way some bought massive numbers of tests, to extend service to their members or employees? Think of the NBA, which set up its own testing apparatus.

Corlette said: “The language is pretty clear that the provider is not supposed to charge the patient if they want to. It’s also early on the vaccines. It’s not like every provider out there is going to be getting these vaccines, at least initially — this is going to a fairly circumscribed group of providers that are part of this vaccine program. Being part of this vaccine program, there are terms and conditions. One of the things that the federal government has said is you cannot charge people for administering this vaccine. It’s free.

“Now, this is America. So whether there’s some kind of side market that springs up where  you can jump the line in some way — I would never say that could never happen. But I’m not totally sure how it could happen and not violate if not the terms, then the spirit of what it means to be part of the CDC vaccine program.“

So how much will patients pay for the vaccine? For those getting vaccinated now, in the first swath, probably nothing. For others, later — it’s hard to predict.

Scams, of course

There are already scams, and there will be more. Medicare recipients, for example, got notified this week to watch out for people trying to get them to pay for the vaccine.

In an email, Medicare wrote:

“As the country begins to distribute COVID-19 vaccines, there’s no doubt scammers are already scheming.

Medicare covers the COVID-19 vaccine, so there will be no cost to you. If anyone asks you to share your Medicare Number or pay for access to the vaccine, you can bet it’s a scam.

“Here’s what to know:

  • You can’t pay to put your name on a list to get the vaccine.
  • You can’t pay to get early access to a vaccine.
  • Don’t share your personal or financial information if someone calls, texts, or emails you promising access to the vaccine for a fee.

“If you come across a COVID-19 vaccine scam, report it to the Federal Trade Commission or call us at 1-800-MEDICARE. And check out CDC.gov for trustworthy information on the COVID-19 vaccine.”

So, what is the actual price of the vaccine?

The different vaccines have different prices, depending on circumstance and customer.

Pfizer, for example, didn’t take any money from Washington for development, but did conclude contracts for sale of the vaccine to Washington. The Pfizer CEO, Albert Bourla, told The Hill in November that the Pfizer vaccine would be free to all Americans because Pfizer sold it to the U.S. government at a low price. That price is reportedly around $20 per dose; Bourla was probably referring to the first 100 million doses Pfizer sold to the government. Pfizer requires two doses several weeks apart for maximum effectiveness.

Moderna, on the other hand, accepted money for development, and it is also charging for the shots. The Moderna CEO told a German paper that it was charging between $25 and $37 a dose for governments to buy it.

AstraZeneca has been saying its vaccine will be priced below $4. It has not been approved for use; the trials are still underway.

A Belgian official posted the prices that the European Union had agreed to pay to manufacturers on Twitter, causing a small firestorm, The Guardian reported in late December.  The price list was removed from Twitter, but it was screenshotted and made public that way. Here’s the list, in black and white, below right.

The price list was controversial, The New York Times reported, because “Another snag in the relationship surfaced Friday when a European official released on Twitter — and then quickly deleted — a price list that showing that vaccine shipments to the U.S. government cost a third more per dose than shipments to European customers.

The Times reported that Pfizer completed a deal   to sell the European Union 200 million doses at $14.50 each. The contract signed by the Trump administration with Pfizer in July for the original 100 million doses put the price at $19.50, The Times reported.

Further exploring the Pfizer relationship with the U.S. government, The Times said, “the president and his top aides have claimed credit for Pfizer’s success, even though, unlike the other five vaccine makers in the Operation Warp Speed program, Pfizer did not take federal subsidies for the vaccine development or manufacturing, assuming all of the risk itself.”

Statista published a graphic with some similar prices — see the colored graphic at right. It was not clear who the customer is in these Statista cases, which seems clearly to affect the price being paid: If the U.S. pays more than European Union countries, no one is likely to be surprised except the U.S. taxpayer.

Here’s what the Centers for Medicare and Medicaid Services says on its Covid vaccine page: “Medicare payment rates for COVID-19 vaccine administration will be $28.39 to administer single-dose vaccines. For a COVID-19 vaccine requiring a series of 2 or more doses, the initial dose(s) administration payment rate will be $16.94, and $28.39 for the administration of the final dose in the series. These rates recognize the costs involved in administering the vaccine, including the additional resources involved with required public health reporting, conducting important outreach and patient education, and spending additional time with patients answering any questions they may have about the vaccine. These rates will also be geographically adjusted.

“Note: these rates don’t apply for entities that are reimbursed for vaccines at reasonable cost.”

Here’s the Medicare billing advice for providers for Covid vaccine administration.

Medicaid, Children’s Health Insurance Plan (CHIP) and Basic plan information from CMS is here.

A general CMS page with further details on the topic is here.

And, the future

Beyond the immediate situation, it’s easy to imagine that the government gets out of the business of supplying vaccines eventually.

Corlette said: “At a certain point, the federal government’s not going to pre-buy all this stuff. And as I understand it, the normal way vaccines are purchased is, providers purchase them: They try to estimate in advance how much they’re going to need and then  submit for reimbursement. At a certain point, I suspect the federal government will step out of the way. But I don’t know for certain that that will happen. And if it does, I don’t know when that would happen.

“There is precedent for the government continuing to purchase this stuff, she added. “There’s the vaccine for children’s program, which has been around for decades. And that is where CDC essentially bulk-purchases vaccines for kids, and then states administer to uninsured kids. That’s a nice model, right? Because you’re getting this bulk government rate, and then it is distributed out three state public health programs. You could potentially see that as a model for Coronavirus, but but the drug companies don’t necessarily think that is the best model — they could probably think they could get a better deal by working through [pharmacy benefit managers] and a private market.”