DMHC issues guidance requiring health plans to cover COVID-19 vaccine administration

December 17, 2020
Area(s) of Interest: Payor Issues and Reimbursement Public Health 

On December 11, the California Department of Managed Health Care (DMHC) issued an all plan letter (APL) and an FAQ instructing health plans of their responsibility to cover COVID-19 vaccine administration.

The guidance states that health plans must cover the administration of qualifying COVID-19 vaccines with no patient cost-sharing. Additionally, during the public health emergency, plans must provide coverage regardless of whether the enrollee receives the vaccine from an in-network or out-of-network provider. Because the federal government is providing the vaccines themselves, there is no reimbursement for the toxoid.

The APL also clarifies the following:

  • Out-of-network providers must be reimbursed at a “reasonable rate,” which the Centers for Medicare & Medicaid Services guidance suggests is the Medicare reimbursement rate for COVID-19 vaccine administration. As a condition of participation in the CDC COVID-19 Vaccination Program, physicians may not bill patients for any balance not paid by the health plan. Click here for more information.
  • Health plans are responsible for payment, even when the covered lives have been delegated to a risk-bearing organization (RBO), unless the RBO has requested in writing that the plan delegate this function to it. If a physician sends a claim for COVID vaccine administration to an RBO but the health plan is responsible for payment CMA believes that California regulations would require RBOs to automatically forward those misdirected claims to the health plan within 10 business days of receipt. Physicians should not need to resubmit claims to the health plan.
  • Coverage for the administration of a particular COVID-19 vaccine must be effective no later than 15 business days after the Advisory Committee on Immunization Practices or the United States Preventive Services Task Force makes an applicable recommendation relating to each brand of vaccine, which for the Pfizer vaccine was Dec. 11, 2020.
  • The FAQ included in the APL confirms that plans may not choose to cover only a subset of qualifying vaccines, as they are required under the CARES Act to cover “any qualifying coronavirus preventative service,” which includes qualifying vaccines.
  • The APL states that DMHC does not anticipate, at this time, that plans will need to impose any utilization management criteria, as providers are required to follow state and federal guidance with respect to who is eligible to receive a vaccine.
  • Health plans are required to cover vaccine administration even if the employer, such as a health facility, chooses to administer the vaccine to its employees.

For more information, see DMHC APL 20-039.


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