COVID-19 Vaccines and Coverage

In the face of the COVID-19 pandemic, pharmaceutical companies have moved to produce vaccines. The Food and Drug Administration (FDA) awarded an Emergency Use Authorization (EUA) to three companies for their vaccines: Pfizer  on Dec. 11, 2020, Moderna  on Dec. 18, 2020, and Janssen Pharmaceutical Companies of Johnson & Johnson  on Feb. 27, 2021. On Aug. 23, 2021, they granted full approval  of the Pfizer COVID-19 vaccine for ages 16 and older. The Pfizer vaccine, known as Comirnaty is also available under EUA for ages 5-15. See the FDA website  for prescribing information.

Booster Shots and Additional Doses: The federal government requires us to cover the COVID-19 vaccine at no cost share through the end of the public health emergency (PHE). This includes COVID-19 booster shots and additional doses. Members may choose to receive the vaccine type they originally received or a different type as a booster shot. CDC recommendations allow for mix-and-match dosing for booster shots. The CDC provides guidance  on the administration of the vaccine. At the end of the PHE, we will provide updates on our coverage.

Initially, the federal government will pay for the vaccine . Blue Cross and Blue Shield of New Mexico (BCBSNM), or self-funded groups, will cover administration of the vaccine as noted below:

Fully insured:

• Vaccine and administration covered as a preventive service with no cost-share to members at in-network providers
• Vaccine and administration covered with no cost-share to members if delivered at out-of-network providers through the end of the public health emergency

Self-funded employer groups:

• Non-grandfathered self-funded employer groups - vaccine and administration covered as a preventive service with no cost-share to members at in-network providers
• Vaccine and administration covered at no cost-share to members at out-of-network providers through the end of the public health emergency
• Self-funded employer groups that don’t cover preventive vaccines through their pharmacy benefit must cover the vaccine through their medical benefit
• Grandfathered plans are not required to cover preventive services, including the COVID-19 vaccine

Medicare Advantage

• Through Dec. 31, 2021: Submit claims for the vaccine and its administration to the CMS Medicare Administrative Contractor using product-specific codes for each vaccine approved. Payment for the vaccine and its administration is through the original fee-for-service Medicare program until the end of 2021.
• Starting Jan. 1, 2022: BCBSXX will cover the cost of COVID-19 vaccines and their administration for Medicare Advantage members. For Medicare Advantage members you vaccinate on or after Jan. 1, follow your normal submission process to BCBSXX or see the member’s ID card for billing instructions.
• Medicare Advantage members will continue to have no cost-sharing during their 2022 benefit year on vaccines and their administration, including approved booster doses.

Medicare Supplement

• Submit claims for the vaccine and its administration to CMS. Payment is through the original fee-for-service Medicare program.

Medicaid

• Most Medicaid members will have no cost-sharing on vaccines from in- and out-of-network providers. See the CMS Medicaid toolkit 

Reimbursement:

• In-network providers will be reimbursed for the administration fee based on contracted rates.
• Out-of-network providers will be reimbursed based on established OON reimbursement policy that follows Medicare rates.

Balance billing: Providers are prohibited from billing patients for the vaccine or its administration, including balance billing, if the provider received the vaccine at no cost from the government.

Coding claims: CMS and the American Medical Association (AMA) have identified the codes to use in submitting claims. For more information, see CMS’ guidance .

When billing a vaccine administration code with an office visit, if the vaccine is not the primary purpose of the office visit, bill the vaccine on a separate claim.

Dosage: Candidate vaccines may require one or two doses. The Pfizer and Moderna vaccines require two doses. The Janssen/Johnson & Johnson vaccine is one dose. Guidance on additional doses is evolving. Follow CDC guidelines 

More information:

• CDC COVID-19 Vaccination Program Interim Playbook  
• Provider Relief Fund – for reimbursement for administering the COVID-19 vaccine to the uninsured
• CMS Medicaid Toolkit - Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost Sharing under Medicaid, the Children’s Health Insurance Program, and Basic Health Program
• CMS guidance  on Medicare billing for the COVid-19 vaccine administration

We continue to monitor information provided by the CDC and other government and health officials. We’ll provide updates when we have them. For the latest information on COVID-19, we recommend visiting the CDC’s COVID-19 website .

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