Health plans will soon be footing the bill for COVID-19 shots, tests

Health insurance companies played a limited role for the most part during the COVID-19 pandemic. In fact, they made a lot of money—especially in 2020—because people put off having surgeries and other procedures.

They’re about to become much more involved as a result of the Biden administration’s decision to stop supplying free COVID-19 vaccines and tests to the public and shift the bill for COVID shots and treatments to health plans.

F. Randy Vogenberg, Ph.D., principal at the Institute for Integrated Healthcare, a consulting company, says that coverage for COVID vaccinations and tests will be included in a health plan’s medical benefits, not pharmacy benefits.

“Anything that has to do with an injection or prevention of a medical condition such as COVID-19, that’s typically what is covered under a medical benefit,” Vogenberg said in an interview. “While the majority of vaccinations will likely occur in a pharmacy today, the pharmacy claim is paid for under the medical plan coverage in commercial insurance, so it is not a pharmacy benefit claim expense.”

More involvement by commercial insurance companies means more involvement—and very likely increased expense—for the businesses that contract with them, says Vogenberg. “What this means for employers is an additional financial burden through increases in premiums or unanticipated added costs if off the existing plan year renewal cycle,” says Vogenberg. “For plan members—employees and family—this can mean increases in out-of-pocket deductibles.”  

The U.S. has one of the lowest COVID-19 vaccination rates in the world, ranking 68th among the world’s nations, according to the Johns Hopkins University Coronavirus Resource Center.

“The loss of [governmental] financial support for vaccinations and testing can only be expected to fuel the pandemic,” Kevin Kavanagh, M.D., founder and president of the patient advocacy group Health Watch USA, said in an interview. “At this point, it is unclear to what extent this shortfall will be picked up by employers or private health insurance coverage. The final cost of the vaccine is also unknown, especially in view of the recent suit filed by Moderna over alleged patent infringement by Pfizer and BioNTech. However, for insurance companies, it is in their best interest to have patients vaccinated and avoid the costs associated with hospitalizations and long COVID. The same is true for private businesses whose workforce is placed at risk by this disease.”

One in five people in the U.S. who have contracted COVID-19 have experienced symptoms of "long COVID," according to the Centers for Disease Control and Prevention (CDC). In an economy in which a labor shortage exists in many industries, long COVID could cause real economic harm, as between 2 million and 4 million workers—or about 2% of the workforce—are not working because of it, according to the Brookings Institute.

Vaccines can greatly reduce the risk of workers developing long COVID, according to recent research in JAMA Network, from about 42% in unvaccinated patients to 16% in those who’ve received three doses of the vaccines.

Shifting the payment from the government to private insurance companies could take months, The Wall Street Journal reports. Dawn O’Connell, the assistant secretary for preparedness and response at the Department of Health and Human Services (HHS), told the publication, "We’ve known at some point we’d need to move over into the commercial market, and we’re approaching that time now. We don’t want to do it by fiat."

In the same WSJ article, Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation, said that the costs for COVID-19 vaccines and tests will almost certainly rise, with each health plan and pharmacy benefit manager having to negotiate with pharmaceutical companies about price.

HHS has scheduled a planning session Aug. 30 and invited major stakeholders such as drugmakers, pharmacies and state health departments to discuss the new policy, according to the WSJ article.