Various laws, regulations, and guidance that federal policymakers put in place since the beginning of the COVID-19 pandemic have expanded access to testing, vaccination, and treatment for the virus. This fact sheet summarizes these provisions and explains how the federal government, the states, and private health care providers can implement them so that all people can get the care they need.
During the Public Health Emergency (PHE) and for more than a year after it ends,[1] Medicaid is required to cover COVID-19 testing, vaccinations,[2] and treatment for most enrollees, and it may not charge cost sharing for these services. The American Rescue Plan Act also provides federal matching funds to cover 100 percent of state Medicaid costs for providing vaccines and administering them starting April 1, 2021 and lasting more than a year after the PHE ends. As part of this benefit, effective December 2, 2021, Administration guidance also requires states to cover COVID-19 vaccine counseling visits for children and youth enrolled in Medicaid as part of the Early and Periodic Screening, Diagnostic, and Treatment benefit.[3]
During the PHE, states also have the option (by filing a Disaster Relief State Plan Amendment with the Centers for Medicare & Medicaid Services) to provide COVID-19 testing and diagnosis, vaccination, and treatment services through Medicaid to people who are uninsured, regardless of their income.[4] This option is especially important now that the federal Health Resources and Services Administration (HRSA) Uninsured Program has exhausted its funds and stopped accepting claims from providers who deliver COVID-19-related services to people who are uninsured. The HRSA program stopped accepting claims for COVID-19 testing and treatment on March 22, 2022 and for vaccines on April 5, 2022.[5] For the Medicaid optional group, individuals must attest that they live in the state and generally must provide a Social Security number.
The Medicaid COVID-19 option also can provide payment for emergency services provided to uninsured people who would be eligible under the option but for their immigration status. (For example, payment could be made for COVID-19-related emergency care provided to uninsured immigrants with income over Medicaid eligibility levels.) States receive federal Medicaid matching funds (officially, the federal medical assistance percentage or FMAP) that cover 100 percent of the costs of the services they deliver to this new optional group, as well as any investments in infrastructure and other administrative costs to implement the option — such as setting up a billing portal for providers or adjusting presumptive eligibility systems to account for this additional group. As of April 2022, 15 states had adopted this option.[6]
The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) recommends the COVID-19 vaccine for children aged 5 and older, so it is included in the federally funded, CDC-administered Vaccines for Children program.[7] That program ensures that children enrolled in Medicaid, children who are uninsured or underinsured, and children who are American Indians or Alaska Natives can get recommended vaccines free of charge. Medicaid covers the cost of vaccine administration for Medicaid-enrolled children. Children enrolled in separate Children’s Health Insurance Program (CHIP) plans are not included in the Vaccines for Children program, but ACIP-recommended vaccinations for children are a required benefit in CHIP.
During the PHE:
- Testing: Most private group and individual market plans (including grandfathered plans, which are plans that existed before the 2010 Affordable Care Act and have not changed significantly since) must cover COVID-19 testing and diagnosis without charging enrollees cost sharing such as copayments or deductibles.[8] Plans cannot require prior authorization for these services, nor can plans and providers require an individual to have symptoms or suspected COVID-19 exposure as a condition of coverage. Beginning January 15, 2022, plans are also required to cover or reimburse enrollees for the cost of up to eight over-the-counter COVID-19 tests per enrollee per month during the PHE.[9] Plans may cover testing for public health surveillance or employment purposes, but they are not required to do so.
Vaccinations: Most private group and individual market plans (but not grandfathered plans) must cover COVID-19 vaccinations (including boosters) without charging cost-sharing amounts or deductibles or requiring prior authorization. Plans may not charge enrollees any cost sharing for an office visit if the main reason for the visit is vaccination. Plans may not offer different coverage for vaccines produced by different manufacturers; all vaccines that ACIP recommends must be covered. Plans cannot deny coverage based on a state’s or locality’s vaccine prioritization schedule (for example, if a person got vaccinated before the state opened vaccinations to their age group). Federal guidance instructs insurers to pay in-network providers the negotiated rate and out-of-network providers “reasonable” rates (for example, the Medicare reimbursement rate).
For people enrolled in plans that do not cover vaccinations or that require cost sharing for vaccinations, providers can submit claims to the federal Health Resources and Services Administration (HRSA) COVID-19 Coverage Assistance Fund (CAF). Vaccine administration fees and any patient cost sharing related to vaccines are eligible for reimbursement through CAF. Providers are reimbursed at Medicare rates and cannot balance bill patients. CAF is funded through the larger federal Provider Relief Fund.
- Treatment: Unlike testing and vaccinations, individuals enrolled in private health insurance have no special financial protections for treatment for COVID-19. Existing cost-sharing charges under a plan (such as copayments, coinsurance, and deductibles) apply. For marketplace enrollees, existing protections apply, such as the annual out-of-pocket maximum for in-network coverage.[10]
How are testing, vaccines, and treatment covered for people who are uninsured?
People who are uninsured should be able to get COVID-19 testing and vaccines at no cost, regardless of income or immigration status. The HRSA COVID-19 Uninsured Program stopped accepting provider claims for treatment services in March 2022, leaving fewer options for people who are uninsured to access free COVID-19-related treatment.
- Medicaid COVID-19 option: If a person who is uninsured lives in a state that has adopted the Medicaid COVID-19 option described above and they’re not eligible under another Medicaid category, they will qualify for services through the option — unless they are not citizens or don’t have a satisfactory immigration status that makes them eligible them for Medicaid. Medicaid payment for emergency services provided to these individuals may be available, however.
- Other states: If an uninsured person lives in a state that has not adopted the Medicaid COVID-19 option, they can seek care at a Federally Qualified Health Center or other state or local health department programs that provide services regardless of insurance or immigration status. Previously, providers could claim reimbursement through the HRSA COVID-19 Uninsured Program, regardless of the individual’s income or immigration status.
| TABLE 1 |
|---|
|
| | Testing | Vaccination | Treatment |
|---|
| Uninsured | - Covered through the Medicaid COVID-19 option if a state adopts it.
- Emergency Medicaid may be available to pay for emergency services for individuals who would qualify for Medicaid but for their immigration status.
|
- People with a fixed address may request a limited number of free at-home COVID-19 tests by mail at COVIDTests.gov (regardless of coverage status) and most Federally Qualified Health Centers and state and local health departments provide free COVID-19 testing
| - Vaccines must be provided at no cost and regardless of coverage or immigration status
| |
| Medicaid enrollees | - Must be covered without cost sharing for full-benefit enrollees. Includes over-the-counter tests, but states may require a prescription or apply other limits.
| - Must be covered without cost sharing, including for limited-benefit enrollees.
- 100% FMAP for vaccine and administration.
| - Must be covered without cost sharing for full-benefit enrollees.
|
| Individuals in Medicaid optional COVID-19 group | - States may take up this option to cover testing, vaccination, and treatment for uninsured individuals, regardless of income.
- Individuals in limited-benefit Medicaid groups qualify for testing and treatment through this option, but vaccines must be covered as part of their limited-benefit Medicaid coverage.
- Immigrants who would qualify for this option but for their immigration status may qualify for payment of emergency services.
- States receive 100% FMAP for services as well as administrative costs to support this optional group.
|
| Enrollees in non-grandfathered group and individual market health plans | - Must be covered without cost sharing (whether delivered by an in-network or out-of-network provider). Includes coverage of/reimbursement for over-the-counter COVID-19 tests obtained on or after January 15, 2022.
| - Regular cost-sharing policies apply.
|
| Enrollees in grandfathered plans | - Must be covered without cost sharing (whether delivered by an in-network or out-of-network provider). Includes coverage of/reimbursement for over-the-counter COVID-19 tests obtained on or after January 15, 2022.
| - May, but are not required to cover vaccinations. Cost-sharing may apply.
| - Regular cost-sharing policies apply.
|
| Enrollees in short-term, limited-duration plans | - May, but are not required to cover testing, vaccinations, or specific treatments. Cost-sharing may apply.
- Not counted as insurance for purposes of eligibility for Medicaid COVID-19 category.
|
The federal government is now buying and distributing all COVID-19 vaccines. As a condition of receiving vaccines, pharmacies and other COVID-19 vaccination providers must vaccinate individuals free of charge, regardless of insurance status or form of coverage. The critical work to ensure that everyone can access vaccines, however, is complex and ongoing.
Various laws have allocated federal funding to support vaccine distribution, outreach, and monitoring efforts. Most recently, the American Rescue Plan Act allocated more than $15 billion to support CDC efforts, the vaccine supply chain, and the vaccine-related efforts of the Food and Drug Administration. The Act also includes nearly $9 billion for public-health-related investments, most — $7.6 billion — of which is allocated for Federally Qualified Health Centers’ COVID-19 testing and vaccine outreach and administration efforts. Another $7.66 billion is allocated to state, local, tribal, and territorial health departments.
