On December 12, 2020, an independent panel of scientific advisors — the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) — approved recommended use of Pfizer Inc.’s COVID-19 vaccine for individuals 16 years of age and older. A day later, Pfizer began shipping 2.9 million doses to 636 sites across the country, prompting the first doses of the vaccine to be distributed to healthcare workers and nursing home staffers.
The ACIP recommendation triggers the requirement for non-grandfathered group health plans and health insurance issuers to cover the vaccine without cost-sharing.
Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), plans and issuers must cover the vaccine within 15 business days and coverage must begin no later than January 1, 2021. However, plans and carriers may choose to cover the vaccine before January 1, 2021 as additional forms of the vaccine are approved by the FDA.
Coverage of COVID-19 Preventive Care Services
Non-grandfathered group health plans and issuers offering group or individual health coverage must cover COVID-19 preventive services, including recommended COVID-19 immunizations, without cost-sharing. Coverage of these immunizations must be provided, even if not listed for routine use on the CDC’s Immunization Schedules.
It is important to note that employer health plans must cover the COVID-19 vaccine, without cost-sharing, regardless of whether the member received the vaccine through an in-network or out-of-network provider.
The special rules described above are planned to expire when the federal government declares an end to the COVID-19 public health emergency. Meaning, the special exception to the 15-day accelerated coverage time frame and requirement to cover vaccines administered by an in-network or out-of-network provider remain, until further notice.
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