Recipients of COVID-19 vaccine boosters won’t have to pay anything out of pocket, CMS confirms

As with the initial vaccination doses, federal funds are available to cover the cost of providing booster doses to the uninsured and underinsured.

CMS will continue to cover the full cost of administering the COVID-19 vaccine as vaccination moves into the booster stage for some Americans.

The FDA and CDC have approved a vaccine booster dose for high-risk populations that initially received the Pfizer/BioNTech vaccine series, including the elderly, people with compromised immune systems and adults who work in occupations or settings that put them at higher risk. The agencies plan to consider boosters for people in those categories who received the Moderna and Johnson & Johnson vaccines.

Medicare beneficiaries will owe nothing out of pocket for receiving an authorized booster dose, and the same applies to almost all Medicaid beneficiaries (excepting those who are eligible only for Medicaid cost-sharing assistance or COBRA premium assistance).

Beneficiaries of most commercial health plans also must have access to the vaccine at no cost. Exceptions may apply to plans that were purchased before the Affordable Care Act (ACA) was signed in March 2010 and to short-term, limited-duration plans. The ACA specifies that non-grandfathered plans must waive cost sharing for immunizations and other types of preventive care, and the CARES Act expanded that requirement to include the COVID-19 vaccine.

COVID-19 vaccine reimbursement policies

As with the initial doses of the vaccine, providers must administer the booster:

• At no out-of-pocket cost to recipients
• Regardless of a recipient’s coverage status or network status
• Without any associated fee for an office visit if the vaccine is the sole medical service provided

Providers may seek reimbursement from a recipient’s private insurance plan, Medicare or Medicaid, or the HRSA COVID-19 Uninsured Program. When a plan is exempt from requirements to cover the vaccine and chooses to offer partial or no coverage, providers still are prohibited from billing the recipient and instead should file to collect the balance from the HRSA COVID-19 Coverage Assistance Fund.

Reimbursement for providing the vaccine to uninsured or underinsured recipients typically is at the Medicare payment base rate, which is $40 per dose.