As you may recall, the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) requires non-grandfathered health plans to cover any in-network qualifying coronavirus preventive service, including the COVID-19 vaccine and its administration, without cost sharing, such as a copay, coinsurance, or deductible. Regulators recently extended this requirement to out-of-network (OON) providers for the duration of the COVID-19 public health emergency (PHE). This change does not apply to grandfathered plans.
What action is needed?
No action is required if your health plan is non-grandfathered (as most are); MedCost is automatically implementing this change without requiring a plan amendment. If your health plan is grandfathered, however, and you want to implement this change to extend coverage for coronavirus preventive services to include OON providers, please contact your MedCost Account Manager. A signed Plan Amendment will be required for grandfathered plans.
How is payment for vaccination from an OON provider determined?
The amount a plan reimburses an OON provider for administration of a COVID-19 vaccine must be reasonable, as determined in comparison to prevailing market rates for the service. MedCost will apply traditional Medicare rates based on regulatory guidance that such rates meet this requirement.
Can plan members be balance billed for vaccinations from an OON provider?
CMS anticipates that all vaccines in the initial phases will be distributed by the federal government and that providers administering vaccines will be subject to government provider agreements. Under these agreements, providers are prohibited from seeking reimbursement from any vaccine recipients for vaccine administration costs—including through cost sharing or balance billing.
What are implications for health care facilities providing vaccinations to employees?
Some health care facilities may absorb the costs of COVID-19 vaccine administration to their own employees, but health care facilities are permitted to bill their health plans for vaccine administration for employees who are covered under the plans.
How long will the OON provisions be in effect?
These OON provisions will sunset at the end of the COVID-19 PHE.
Your MedCost Account Manager will continue to work directly with you to address your specific circumstances and needs. Remember to check our COVID-19 webpage for current information.