Whether you have insurance or not, there should be no out of pocket cost to get vaccinated.

By Mia Taylor
February 26, 2021
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How much does the COVID-19 vaccine cost, you ask? Well, although government and health officials have been working to spread the message far and wide, there continues to be some confusion about the new vaccine's accessibility and pricing in the United States—and whether insurance covers it. So, let's clear things up. Whether you're insured or uninsured, the out-of-pocket fee for vaccination is exactly the same: zero.

The vaccine is free, for everyone; the federal government is footing the bill for all those who live in the United States. And for good reason, Sanjiv Shah, MD and chief medical officer for MetroPlus Health, tells Health: "I think for the foreseeable future this vaccine will be provided free of charge because of the virus' impact on everyone," says Shah. "We don't want price to be a barrier. We're striving toward herd immunity, and the only way to achieve that is to make sure everyone gets vaccinated."

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Credit: Alex Sandoval

There's currently two FDA-approved vaccines available in the United States, produced by Pfizer and Moderna, and to date some 66,464,947 doses have been administered, according to the latest figures from the Centers for Disease Control and Prevention (CDC). Still, questions persist about whether there will be any unexpected costs associated with the vaccination process.   

Insured, uninsured—it's all the same

The Centers for Medicare & Medicaid Services (CMS) has spelled out for providers and insurers that vaccines must be given regardless of an individual's ability to pay—or their health insurance coverage status. The CMS also specified that providers may not seek any type of reimbursement from individuals such as co-pays or balance billing. 

In other words, there should be no cost share, no deductible, and no charge of any kind that you're asked to pay, says Shah.

"Occasionally certain localities may ask if you have insurance, but that's not to cover the cost of the vaccine," says Shah. "They may ask because they're going to bill your insurance carrier for administration of the vaccine."

The cost of vaccine administration—in other words, the cost of providing the staff to inject the dose in your arm and conduct public health reporting—has been the source of at least a few billing hiccups or questions. Some vaccine providers may charge the patient an administration fee, but even that cost is supposed to be covered by your insurance company or, in the case of those who are uninsured, by the Health Resources and Services Administration's Provider Relief Fund.

"There's always a wrinkle here and there, but right now the rule is that the vaccine and its delivery is to be covered," Kim Buckey, vice president of client services for DirectPath, a company that helps employees make health care decisions, tells Health.

Those who receive a bill for vaccine administration should file a reimbursement claim with their health insurance company, says Bucky. If you don't have health insurance, reach out to the provider who administered the vaccination to discuss the charge and potential resolution.

"What's supposed to happen is the provider is supposed to file a claim with the government agency administering reimbursement," says Buckey. "But it is always possible that a provider could charge you. For that reason, it's always a good idea to call a provider before you get the shot, so you understand what the rules will be."

Affordable Care Act loophole

Under the Affordable Care Act, insurers are required to cover the cost of any COVID-19 vaccine recommended by the CDC's Advisory Committee on Immunization Practices (ACIP). But therein lies a loophole: millions of Americans have health insurance plans that existed before the Affordable Care Act was enacted. These plans, often referred to as "grandfathered" health plans, are exempt from following ACA rules and thus not required to fully cover costs associated with COVID-19 vaccination, analyst Michael Giusti of insuranceQuotes, explains to Health. Short-term plans and Farm Bureau plans are also exempt from ACA rules.

"The question mark comes in when someone has a plan that's not regulated," says Giusti. "In some cases, states are requiring those plans to cover the costs of the shot, but others may not."

Even here, however, the cost should still not be paid by the patient, Giusti explains, because those with grandfathered health plans are supposed to be considered uninsured for the purposes of COVID-19 vaccination—and as already noted, the uninsured have equal access to free vaccine doses. "So, it still wouldn't come out of pocket," says Giusti.

But the American health care system is nothing if not complex, and it always pays to do your research and ask questions ahead of time, Giusti adds. "There could be a scenario where you went to a pharmacy to get the vaccine or to a private provider, not knowing you have a grandfathered health insurance plan, and later the charge for the vaccine is declined by your insurance," he explains. "We've all had those kinds of bills show up after the fact."

If you're on the receiving end of such a bill, don't automatically assume you're on the hook for the vaccination charges. Instead, "reach out to the provider who administered the vaccine and ask that they file a claim with the Provider Relief Fund," recommends Giusti.