AZ Regulatory Bulletin 2020-07: Coverage of COVID-19 Vaccines

OFFICE OF THE DIRECTOR

Arizona Department of Insurance and Financial Institutions

100 North 15 th Avenue, Suite 261, Phoenix, AZ 85007-2630

Phone: (602) 364-3100 | Web: https://difi.az.gov

Douglas A. Ducey, Governor

Evan G. Daniels, Director

Regulatory BulleƟn 2020-07 1

Coverage of COVID-19 Vaccines

Pursuant to Arizona Revised Statutes (ARS) §§ 41-1001(22) and -1091, the Arizona Department

of Insurance and Financial InsƟtuƟons (the “Department”) occasionally issues SubstanƟve Policy

Statements to provide guidance regarding common compliance maƩers, recurring quesƟons, or

maƩers of public importance. SubstanƟve Policy Statements are intended to promote a level

playing field and uniform applicaƟon of statutory or regulatory provisions.

I. Purpose

The purpose of this SubstanƟve Policy Statement is to address ExecuƟve Orders 2020-57 and 58.

II. Scope

This SubstanƟve Policy Statement is intended to provide guidance to all insurers subject to

ExecuƟve Orders 2020-57 and 58.

III. Background

On November 18, 2020, through ExecuƟve Order 2020-57 , Arizona Governor Doug Ducey

mandated that "all insurers regulated by the State cover influenza and pandemic vaccines and

administraƟon without regard to whether the provider is in-network." In addiƟon, the federal

Cares Act established that COVID immunizaƟons must be provided at no cost-sharing for

non-grandfathered group and individual plans.

1 This substanƟve policy statement is advisory only

administraƟon without regard to whether the provider is in-network." In addiƟon, the federal

Cares Act established that COVID immunizaƟons must be provided at no cost-sharing for

non-grandfathered group and individual plans.

1 This substanƟve policy statement is advisory only. A substanƟve policy statement does not

include internal procedural documents that only affect the internal procedures of the agency

and does not impose addiƟonal requirements or penalƟes on regulated parƟes or include

confidenƟal informaƟon or rules made in accordance with the Arizona administraƟve procedure

act. If you believe that this substanƟve policy statement does impose addiƟonal requirements

or penalƟes on regulated parƟes you may peƟƟon the agency under secƟon 41-1033, Arizona

Revised Statutes, for a review of the statement.

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IV. Department’s Guidance

ExecuƟve Order 2020-57 applies to insurers regulated by the Department. The order requires

plans to cover both influenza and pandemic vaccines regardless of whether the provider is out

of network and regardless of whether the vaccine is administered in mulƟple doses. The Cares

Act also requires coverage regardless of the type of provider. Vaccines may be administered by

physicians, pharmacies, faciliƟes, organizaƟons, public/county health clinics or others

parƟcipaƟng in the federal COVID-19 VaccinaƟon Program

is administered in mulƟple doses. The Cares

Act also requires coverage regardless of the type of provider. Vaccines may be administered by

physicians, pharmacies, faciliƟes, organizaƟons, public/county health clinics or others

parƟcipaƟng in the federal COVID-19 VaccinaƟon Program. County health clinics are permiƩed

to bill like any other provider for vaccines. Insurers will need to establish flexible methods for

receiving claims from atypical health providers administering the vaccine.

All types of health insurance plans that provide coverage for vaccines, including major medical,

short term, and limited benefit plans, must cover the influenza and pandemic vaccines and the

administraƟon of these vaccines by in- and out-of-network providers with no cost-share to the

member. This includes plans offered by health care service organizaƟons (HCSO) which require

members to receive covered services through network providers except in cases of network

excepƟon or emergency. 2 ExecuƟve Order 2020-07 establishes the existence of an emergency

in this State. Therefore, HCSOs and other types of insurers are expected to provide coverage for

influenza and pandemic vaccines, and administraƟon of those vaccines, at no cost to the

member regardless of the provider’s network affiliaƟon

shes the existence of an emergency

in this State. Therefore, HCSOs and other types of insurers are expected to provide coverage for

influenza and pandemic vaccines, and administraƟon of those vaccines, at no cost to the

member regardless of the provider’s network affiliaƟon.

Even if an individual is uninsured, or has a health plan that does not cover vaccines, providers

enrolled in the CDC COVID-19 VaccinaƟon Program must administer vaccines without cost-share

and without balance billing. The provider can seek reimbursement for the administraƟon of the

vaccine through the Provider Relief Fund .

In addiƟon to ExecuƟve Order 2020-57, a significant amount of federal guidance and regulaƟons

also are relevant to these circumstances. The Centers for Medicare and Medicaid (CMS) has

issued a number of documents that insurers will find instrucƟve, including:

●

Toolkit on COVID-19 Vaccine: Health Insurance Issuers and Medicare Advantage Plans -

hƩps://www.cms.gov/files/document/COVID-19-toolkit-issuers-MA-plans.pdf

●

Provider Enrollment, Billing and AdministraƟon resource toolkit -

hƩps://www.cms.gov/covidvax-provider

●

VaccinaƟon Partner FAQ -

hƩps://www.cms.gov/files/document/covid-vax-partner-toolkit.pdf

●

Interim Final Rule with Request for Comment (CMS-9912-IFC)-

hƩps://www.cms.gov/files/document/covid-vax-ifc-4.pdf

●

Vaccine AdministraƟon for the Uninsured

2 See ARS §§ 20-2801 et seq., AAC R20-6-1902, R20-6-1904(B) and R20-6-1910.

ovidvax-provider

●

VaccinaƟon Partner FAQ -

hƩps://www.cms.gov/files/document/covid-vax-partner-toolkit.pdf

●

Interim Final Rule with Request for Comment (CMS-9912-IFC)-

hƩps://www.cms.gov/files/document/covid-vax-ifc-4.pdf

●

Vaccine AdministraƟon for the Uninsured

2 See ARS §§ 20-2801 et seq., AAC R20-6-1902, R20-6-1904(B) and R20-6-1910.

Page | 3

The CMS COVID-19 Vaccine Toolkit states "Consumers enrolled in non-grandfathered group or

individual health insurance coverage will be able to receive the vaccine and its administraƟon

free of charge from a network provider, and during the COVID-19 [public health emergency],

will also be able to receive the vaccine and its administraƟon free of charge from an

out-of-network provider. Providers are prohibited by agreement with the U.S. Government

from billing paƟents for the vaccine or its administraƟon, including balance billing." The toolkit

explains that providers who administer the vaccine to paƟents whose insurance "does not

provide coverage of vaccinaƟon administraƟon fees" can file a claim with the aforemenƟoned

provider relief fund "but may not charge enrollees directly for any vaccine administraƟon costs."

Insurers should note that a COVID-19 vaccine will be considered a preventaƟve service if it has

in effect a recommendaƟon from the Advisory CommiƩee on ImmunizaƟon PracƟces of the

Centers for Disease Control and PrevenƟon (regardless of whether the immunizaƟon is

recommended for rouƟne use)

ld note that a COVID-19 vaccine will be considered a preventaƟve service if it has

in effect a recommendaƟon from the Advisory CommiƩee on ImmunizaƟon PracƟces of the

Centers for Disease Control and PrevenƟon (regardless of whether the immunizaƟon is

recommended for rouƟne use). 3 Therefore, the vaccine must be provided to health plan

members at zero cost-share (i.e. no copay, no coinsurance, no deducƟble). This prohibiƟon is

reinforced by the provisions of ExecuƟve Order 2020-58 Ensuring the Availability of the Vaccine

Without Financial Barriers which requires regulated insurers to “waive all cost-sharing for

consumers related to the administraƟon of all COVID-19 vaccinaƟons and without regard to

whether the provider is in-network.” In addiƟon, insurers must ensure that their members are

not balance billed in accordance with the federal guidelines. Insurers are encouraged to read

CMS guidance regarding the reasonable reimbursement of out of network providers.

Issued December 4, 2020

3 See 45 CFR § 147.130(a)(1)(v).