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Non-grandfathered Plans Must Cover COVID-19 Vaccine Without Cost-sharing Beginning in 2021

On December 11, 2020, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) for Pfizer Inc.’s COVID-19 vaccine. This EUA allowed distribution of the vaccine to begin immediately in the United States.

The day after the FDA approved the vaccine, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended use of the vaccine for individuals 16 years of age and older.

The ACIP recommendation triggers the requirement for non-grandfathered group health plans and health insurance issuers to cover the vaccine without cost sharing under the Affordable Care Act’s preventive care requirements.

Under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act), coverage of the vaccine must be provided within 15 business days after the recommendation is made.

There is some uncertainty regarding the timing, but it is widely understood that coverage of the COVID-19 vaccine must begin no later than January 1, 2021.

Plans and carriers may choose to cover the vaccine before this date. Grandfathered plans may also choose to cover the vaccine, and could be required to do so under state law or pursuant to the terms of an insurance policy.

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