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Decision: unknown

The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.

The rules say a health plan must disclose to its enrollees in clear, accurate terms all cost-sharing information (such as copayments, deductibles and coinsurance). You can find this rule at 42 CFR Section 422.111(a) and (b). 

The rules say that immunizations are not covered unless they are directly related to the treatment of an injury or direct exposure to a disease or condition. In the absence of injury or direct exposure, vaccination or inoculation is not covered. However, pneumococcal, hepatitis B, influenza virus vaccines, and any FDA-approved COVID-19 vaccines are exceptions to this rule. You can find this rule at 42 CFR Section 411.15(e) and Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).

Under sections 1852(a)(1) and 1876(c)(2) of the Act, Medicare Advantage (MA) plans and cost plan organizations must cover all benefits covered under Part A and Part B of Original Medicare, subject to limited exclusions. Therefore, all MA plans and cost plans must cover a COVID-19 vaccine and its administration described in section 1861(s)(10)(A) of the Act. As described previously, the interpretation of section 3713 of the CARES Act adopted in this rule will result in Part B coverage of a COVID-19 vaccine for which FDA issues an EUA during the PHE, and administration of that vaccine when furnished consistent with terms of such EUA. As amended by section 3713 of the CARES Act, section 1852(a)(1)(B)(iv)(VI) of the Act prohibits MA plans from using cost sharing that exceeds the cost sharing imposed under original Medicare for a COVID-19 vaccine and its administration when MA coverage is provided because they are covered under Part B under section 1861(s)(10)(A) of the Act. You can find this rule in the Federal Register / Vol. 85, No. 216 / Friday, November 6, 2020 / Rules and Regulations.

Medicare Billing for COVID-19 Vaccine Shot Administration
There's No Out-of-Pocket Cost for Your Patients

Patients can get the COVID-19 vaccine without a physician's order or supervision, and they pay nothing for the vaccine and its administration. If you participate in the CDC COVID-19 Vaccination Program, you must:

- Administer the vaccine with no out-of-pocket cost to your patients for the vaccine or administration of the vaccine
- Vaccinate everyone, including the uninsured, regardless of coverage or network status

You also can't:

- Balance bill for COVID-19 vaccinations
- Charge your patients for an office visit or other fee if COVID-19 vaccination is the only medical service given
- Require additional medical or other services during the visit as a condition for getting a COVID-19 vaccination

You can find this information at https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccine-shot-administration.

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.

The Plan contract says that the Plan covers items and services in accordance with Medicare rules.