Covid Vaccine: Should You Pay Out of Pocket for Your Shot?

The Centers for Disease Control and Prevention (CDC) recently recommended that everyone six months and older get an updated COVID-19 vaccine, with updated vaccines from Pfizer-BioNTech and Moderna hitting the market.

The recommendation comes following the spread of a new COVID subvariant, BA.2.86., which led some organizations to re-adopt preventative tools such as mask-wearing.

The boosters made by Pfizer-BioNTech and Moderna were approved by the Food and Drug Administration (FDA) earlier this month. A panel of advisers to the CDC voted 13-1 in favor of its broad use for individuals six months and older due to fears of increased respiratory illnesses nationwide this fall and winter.

The new vaccines will be available at national pharmacies including CVS and Walgreens, and at local pharmacies, doctors' offices and public health departments based on location.

The U.S. government began to phase out the procurement and distribution of the COVID-19 vaccine on August 3, 2023.

Although both insured and non-insured Americans should be able to receive their vaccine for free, there have been reports of unexpected charges. CBS News reported earlier this week claims of surprise charges of anywhere between $125 to $190.

Should You Pay Out of Pocket for the COVID Vaccine?

The U.S. Department of Health and Human Services (HHS) has said that vaccines will remain free for most U.S. residents through the Vaccines for Children Program, Children's Health Insurance Program, most commercial insurance, Medicare, and Medicaid programs.

For those who are uninsured or underinsured, the Bridge Access Program for COVID-19 Vaccines and Treatment Program will provide free coverage for uninsured and underinsured Americans.

As stated in a July 2023 HHS letter addressed to Medicare Plans, Private Insurance Plans, State Medicaid and CHIP Programs "most private health insurance, like employer-sponsored plans, Marketplace plans, and other individual market coverage that is subject to the Affordable Care Act (ACA) market reforms are required to cover vaccines for COVID-19 authorized for emergency use or approved by the FDA and recommended by the ACIP and their administration, without patient cost-sharing."

A spokesperson for HHS told Newsweek that while there had been reports of "unexpected coverage denials at the point of service," these were being addressed by the government's Centers for Medicare and Medicaid Services.

"We are aware that some consumers have experienced unexpected insurance coverage denials at the point of service," the spokesperson said.

"After hearing reports of issues, CMS immediately began reaching out to insurance plans to work out remaining issues, to make sure their systems were up-to-date, and to remind them that they 'must cover, without cost sharing, any COVID-19 vaccine authorized under an Emergency Use Authorization (EUA) or approved under a Biologics License Application (BLA) by the FDA immediately upon the vaccine becoming authorized or approved'—a requirement that became binding on September 11, 2023.

"The Biden administration will continue working to ensure COVID-19 vaccines are widely available to the American public at no cost to them from their local provider, community health center or pharmacy. Our message is simple, if you are being turned away for no coverage, please call your insurance for details about in-network coverage to receive the updated COVID-19 vaccine."

The spokesperson added that as long as plans were ACA-compliant vaccines would be covered. The exception was grandfathered plans i.e. plans retained prior to the ACA (under which insurers, payors, and pharmacists are compelled to provide coverage).

They also said that while most plans cover COVID-19 vaccines at no cost as a preventative service, under the Affordable Care Act, individuals and employees were allowed to retain coverage passed before the Act's passage.

"These 'grandfathered plans' are not required to cover certain preventive services at no cost sharing when using in-network providers," they said. "This includes the FDA-authorized COVID-19 vaccines. Members who have questions about their coverage should call the customer service number on their member ID."

This same message was provided by insurers, such as Health Care Service Corporation, which told Newsweek that for most of its members "the COVID vaccine is covered at no cost as a preventive service when using either an in-network provider or pharmacy."

This was echoed by Walgreens. A representative told Newsweek via email that "everyone who is eligible and wants a vaccine receives one."

"COVID-19 vaccines will continue to be available at no cost to the public," they added. "The cost will either be covered by insurance or government assistance programs, such as the CDC's Bridge Access Program.

"We are working closely with manufacturers and distributors to ensure all our stores and their communities have the newly updated COVID-19 vaccines," the representative said. "Most Walgreens stores now have supply to support existing patient appointments and additional appointments are being made available as supply comes into our sites."

So, it appears that provided your coverage is not a grandfathered plan retained prior to the Affordable Care Act, you should not have to pay out of pocket for your coverage.

If you are covered and find your coverage has been denied, speak to your insurer or healthcare provider to ensure it has updated its systems and to receive your vaccine, which will be covered under most plans. Under or uninsured Americans will be able to receive their vaccine through the Bridge Access Program.