Insurers Will Play Key Role in COVID Vaccine Distribution, Reimbursement

by Brian Eastwood

As details continue to emerge about the availability of COVID-19 vaccines and how they will be administered, the role that payers will play in the process is becoming clearer.

It's imperative for health plans to do two key things at the same time, according to Katherine Dallow, M.D., the vice president of clinical programs and strategy at Blue Cross Blue Shield of Massachusetts. Payers need to help the entities that will be distributing the vaccine to identify the individuals who should be first in line to be vaccinated, and they need to use their resources to help educate the community.

"We might be able to put a puzzle together that an individual provider or group may not have," she said during a Nov. 18 National Institute for Health Care Management (NICHM) Foundation webinar. "Data from many sources should be used to ensure those who are most vulnerable are ID'd per federal and state guidelines. We can see where folks have seen three different doctors, used telehealth and gone to urgent care."

In addition, health plans are more likely than providers to have better data about whether individuals have received each of their vaccine doses. That's because states may expand the scope of the type of providers that can administer vaccines in an effort to broaden access.

While multiple vaccines appear ready to come to market, health plans do have some concerns. According to a recent Avalere Health survey of 39 U.S. health plans and one PBM, collectively representing about 48 million covered lives, the effectiveness of vaccines and therapeutics is the top COVID-19 concern for more than 47% of health plans.

For 25% of plans, their top concern is the cost of a vaccine. That said, 50% of payers expect to begin reimbursing for a COVID-19 vaccine within two months of authorization, and 78% expect to begin reimbursing in four months.

CMS released an Interim Final Rule with Comment Period on Oct. 28 requiring that all non-grandfathered individual and group private health plans cover a recommended COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing. The rule also says that "out-of-network rates cannot be unreasonably low," and suggests as a reimbursement guideline the approved Medicare payment rate for a COVID-19 vaccine, which is $28.39 for a single dose and $16.94 for additional doses.

From RADAR on Drug Benefits