Addressing Challenges Getting the New COVID-19 Vaccines

Updated booster campaign marks commercial rollout

September 26, 2023

The federal government is calling on insurers to provide coverage for the updated COVID-19 vaccines that became available earlier this month.

In a letter last week, the U.S. Department of Health and Human Services Secretary Xavier Becerra responded to reports that thousands of people are receiving coverage denials for the updated vaccines. He indicated that some insurers may be dealing with issues beyond their control, but that they are required to ensure their members have access to these vaccines without cost sharing.

“We want to underscore the public health importance of reducing barriers to coverage however possible and urge you to consider any and all ways to reduce these barriers,” Becerra wrote in the letter to the health care payor community. "It is critical to help your members navigate your network, particularly to help people understand the differences between your medical and pharmacy network as appropriate."

Here’s what you need to know:

• What’s changed?:  This updated booster rollout marks the transition of the COVID-19 vaccine campaign to the commercial market. CMS contacted health care payors ahead of the booster rollout with a reminder of the requirement for “most plans and issuers to cover the updated COVID-19 vaccines from Pfizer and Moderna without cost sharing.”
  • With the end of the public health emergency, COVID-19 vaccinations from out-of-network providers are no longer automatically covered. Plans must cover these out-of-network preventive services if they do not offer them within their own network, Becerra noted.
• About the shot:  On September 11, the FDA authorized the updated mRNA vaccines Pfizer-BioNTech and Moderna. These updated shots target the omicron variant XBB.1.5 to provide protection against circulating strains.
• For consumers:   The Kaiser Family Foundation has created a cheat sheet outlining insurance coverage requirements for those with private and public health plans, and options for those who do not have coverage.
• Bridge access program:  The CDC has launched a new program to ensure no-cost COVID-19 vaccines to adults without health insurance and adults whose insurance does not cover all COVID-19 vaccine costs.
• Quotable:  “According to CDC, for every 10,000 vaccinations given to people 65 and over last winter, about 40 hospitalizations are prevented,” Becerra wrote. “With claims rejections in the thousands each day, we are missing opportunities to save lives together.”

HAP continues to monitory the latest COVID-19 public health developments and provide updates to members.  The federal letter to the health care payor community is available online.