The COVID-19 Vaccine

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Now that the COVID-19 vaccine has been approved, things are moving very quickly, and new information is being released often. As we know more, we’ll continue updating this page and communicating with you. 

Keep in mind that vaccine distribution plans are being determined by each state. In most cases, frontline workers and those who are deemed “high risk” will receive the vaccine first. Plans for a general population rollout are still a few months away.

General Vaccine

I’m hearing a lot about a COVID vaccine – when can I get one?

COVID-19 vaccines have been approved for use in the United States. The rollout and distribution will be determined by each individual state and the CDC has set guidelines to help with those decisions. 

In most cases, frontline workers — including medical professionals, first responders, or those working in health care facilities — will receive the vaccine first. The next group will be individuals deemed as “high risk,” meaning they are of a certain age or have a particular health condition. A broader distribution to the remaining general population will come later. 

Check with your state and local health departments to see when the vaccine will be available to you.

How can I get a vaccine once it is available to me? Where can members go to receive the vaccine?

Once the vaccine is available as determined by your state, you and your Highmark members can get the COVID-19 vaccine at a convenient location, most likely a pharmacy.

You can search for locations at VaccineFinder.org. Remember, some vaccines require two doses to be effective. It’s extremely important you get both and follow the suggested timeline.

How much will a vaccine cost?

Members can get a COVID-19 vaccine at no charge. 

Will there be a cost for groups?

Fully Insured – No, regulations require health plans to cover COVID-19 vaccinations at 100% through the duration of the Public Health Emergency. Also, members are permitted to receive the vaccine from an in-network or out-of-network provider.

ASO/Self-funded - During the Public Health Emergency, the cost associated with the actual vaccine from the pharmaceutical supplier is being funded by the federal government. It is expected that government funding this will continue throughout 2021. Claims for the cost of the vaccine should not be submitted to the insurance carrier. However, ASO clients are required to cover the cost of the administration of the vaccine. 

Price ranges associated with vaccine administration are as follows:

  • First dosage = $18 - $21
  • Second dosage = $30 -$35

At the end of the Public Health Emergency, the vaccination, the vaccine will most likely be covered under the preventive services category of benefits for both fully insured and self-insured plans. Further direction will be communicated relative to required benefit updates post crisis.

Can a self-funded group opt out of covering the vaccine?

Non-grandfathered self-funded groups must cover the vaccine as a preventive benefit.

What can I do until the vaccine is available to me?

Until the vaccine is available, everyone should continue following CDC guidelines, including washing their hands often, keeping a social distance, wearing a mask, cleaning and disinfecting commonly used areas, and monitoring your health daily. The CDC also recommends consulting with your health care provider to make sure you have all other recommended vaccines, including the flu shot.

I’m worried about the safety of the vaccine and any possible side effects. Where can I get more information?

If you have questions about the vaccine, side effects, or how it may interact with any drugs or other vaccines you’ve taken, please contact your health care provider.

I’m hearing there are different vaccines that will be available. Which one should I get?

The CDC will issue guidelines to help states develop their vaccine programs, including which vaccine will be available where and when. Check with your state and local health departments to see which vaccine will be available to you based on your situation.

In Pennsylvania, visit health.pa.gov.

In Delaware, visit dhss.delaware.gov.

In West Virginia, visit dhhr.wv.gov.

My employees aren’t in the group that will get the vaccine in the first round, but they need to be tested before they can return to work. Will Highmark cover that?

Highmark is covering testing for COVID-19 only if it is recommended by a clinician based on each person’s symptoms and circumstances.

How can members stay up to date on all things COVID-19, including the vaccine?

Members can get news, updates, and more FAQs at FAQS.MyBenefitsHome.com/Vaccine.

Is Aunt Bertha still in use?

Aunt Bertha is available but more commonly referred to as “community resources”.

When will this be added to the preventive schedule?

ACIP meets in February and will advise the CDC on 2021 immunization updates for the preventative schedule. These will go into effect on the preventive schedule during the mid-year changes on 7/1/2021.

Fully-Insured Plans

Does the cost of the vaccine count as a paid claim or is the cost of the vaccine picked up by the government? How is Highmark handling this?

The cost of the vaccine itself will be paid by the federal government for a period of time. Highmark will pay for the administration of the vaccine. Members will pay $0 cost sharing for vaccine administration, except in the case of grandfathered plans which do not choose to waive cost-sharing.

Does the cost to administer the vaccine count as a paid claim or is this cost picked up by the government?

The cost to administer the vaccine counts as a paid claim.

Is there a time period for these guidelines? When would it start and when would it stop?

Because there are no specific details as to how long the federal government will cover the cost of vaccine or when the public health emergency period will end, it is difficult to determine how long these guidelines will be in place.

Does the group have the option to opt out of covering the vaccine or the administration?

The group does not have an option to opt out of covering the vaccine or its administration.  However, groups with grandfathered plans, although not required to do so, may choose to waive cost-sharing for vaccine administration.

When does a client need to sign an indemnification letter?

Only non-grandfathered ASO groups that decide to opt-out of the immunization cost share waiver or deviate in any way from what we are doing. Grandfathered groups will not be asked to sign an indemnification letter.

Self-Funded Groups

Does the cost of the vaccine get paid by the group or the government?

The government will pay for the “first wave” of the vaccine, which we believe to be most of 2021. The group must pay for the administration of the vaccine. Members will pay with $0 cost sharing for the vaccine administration, except in the case of grandfathered plans which do not choose to waive cost-sharing. Any payments for vaccines delivered in future years and not paid by the government would be the responsibility of self-funded groups.

Does the cost to administer the vaccine get paid by the group or the government?

The group is responsible for the cost to administer the vaccine.

Price ranges associated with vaccine administration are as follows:

  • First dosage = $18 - $21
  • Second dosage = $30 -$35

Can a group opt out or not cover the administration?

 An indemnification from self-funded groups that opt out of covering the vaccine or vaccine administration will be required, as this is a preventive benefit mandated by the federal government. If you choose not to cover, you will be opting out of the CARES Act.

Is there a time period for these guidelines? When would it start and when would it stop?

Because there are no specific details as to how long the federal government will cover the cost of vaccine or when the public health emergency period will end, it is difficult to determine how long these guidelines will be in place.

COVID-19-related Claims

What is the cost per test? Who is paying?

A COVID-19 test costs about $100 per test. In addition to the test, there may be related services, such as Urgent Care or office visit fees, other tests, etc. that average between $50 – $100. Test costs will be covered under Highmark fully-insured health plans, but self-funded groups must pay for testing.

Will there be a cost for employers? 

Will there be a cost for employers?  We have no information on the cost of the vaccine at this time. The federal government plans to shoulder the cost of vaccines through 2021. This is subject to change recognizing that President Elect Biden and the new Congress may extend this coverage.

What is the average cost for a member who tests positive for COVID-19 but is not hospitalized?

Most members have no additional care after testing positive and being instructed to quarantine at home. Treatments for COVID-19 continue to evolve rapidly, so we do not have an estimate for the cost of follow-up care at this time.

What is the average cost for a member who tests positive for COVID-19 and requires hospitalization?

Routine inpatient admissions average about $30,000, while intensive care unit admissions average about $80,000. These costs include follow-up care.

Is COVID-19 testing covered under your member’s health plan? Will over-the-counter testing be covered?

In order for a COVID-19 test to be eligible for coverage under your health plan, there’s some important criteria that must be met. In fact, ALL of the following must be confirmed before a test can be approved.

First and foremost, all tests must be ordered by a licensed health care professional unless the test is being ordered prior to an elective surgery. If deemed clinically appropriate, your physician must come to the conclusion that you’re showing signs and symptoms typically associated with COVID-19 — fever, cough, shortness of breath. In the event that you’re asymptomatic, a health care provider must determine that you’ve had known or suspected recent exposure to someone with the virus before a test can be performed.

If the order for a test meets the coverage criteria above, the sample must be collected by authorized health care personnel, or by a self-collect kit used at home when a health care provider deems it appropriate

Acceptable COVID-19 diagnostic tests may include:

Tests approved by the FDA

Tests authorized by the FDA under an emergency use authorization (EUA)

Tests for which the developer of the test has requested or intends to request EUA (until the request is denied or the developer does not submit the request within a reasonable time)

Tests that are developed in or authorized by a State

Tests that are determined to be appropriate by the secretary of Health and Human Services (HHS)

As of now, COVID-19 diagnostic testing remains limited to tests which meet the above guidelines. In the event that an employer requires a test that is not medically necessary — for instance, as part of a return-to-work protocol — costs will not be covered. Over-the-counter tests will not be applicable for reimbursement.

What additional details surrounding financials for ASO clients are available? Will the government funding be coordinated through the provider, in which case the provider will only bill for the administration?

Providers are receiving the vaccine at no cost and are not billing and/or not being reimbursed for the vaccine itself.  Providers are billing and being reimbursed for administration of the vaccine.  Highmark is allowing coverage of the administration of the vaccine through either the medical or pharmacy benefit to facilitate access to the vaccine through any channel available to our members.

Will this be covered under Medical or Pharmacy?

Vaccine administration will be covered under Medical.

Any other claim numbers that you think would be helpful?

We’re currently looking into the financials and analytic models regarding specific financial questions and will release more related FAQs soon.