Amid concerns that San Benito County residents are being charged administrative fees for the COVID-19 vaccine, Pinnacle Healthcare CEO Ernesto Alvero said all providers are following guidelines provided by the Centers for Medicare and Medicaid Services (CMS). The guidelines allow medical providers to charge a fee to insurance companies only.
“If you go to Safeway or Rite Aid they ask for an insurance card, ID and process the claim that is sent to the insurance,” Alvero said. “The insurance is billed an admin fee. No fee for the actual vaccine because it’s free, but the administration fee is universally accepted.”
Alvero said residents without insurance don’t pay the $40 administration fee and the provider absorbs the cost.
According to CMS guidelines, “Providers that receive the COVID-19 vaccine free from the federal government are prohibited from seeking reimbursement from consumers for vaccine administration costs—including through cost sharing or balance billing. Providers that administer vaccinations to patients without health insurance or whose insurance does not provide coverage of vaccination administration fees, may be able to file a claim with the provider relief fund, but may not charge enrollees directly for any vaccine administration costs.”
The language is consistent with guidelines from the Centers for Disease Control and Prevention, which states providers cannot:
- Charge the recipient for the vaccine
- Charge the recipient directly for admin fees, copays or coinsurance
- Deny vaccination to recipients who don’t have health insurance, are underinsured or out of network
- Charge an office visit or other fee to the recipient if the only service provided is a COVID-19 vaccination
- Require additional services in order for a person to receive a COVID-19 vaccine (but additional health care services can be provided at the same time and billed as appropriate)
While vaccine providers can seek reimbursement for an administration fee from a recipient’s health care plan—including private health insurance, Medicare and Medicaid—the CDC says that providers can’t charge a recipient for the balance of the bill.
Alvero said the claim that Pinnacle Healthcare is charging patients administration fees to make money is false.
“That made me kind of nauseous, to be honest,” Alvero said. “We’ve been in the community for 22 years.” He added that a large portion of Pinnacle’s patients are from underserved communities, such as agriculture workers through workers’ compensation.
San Benito Health Foundation also bills insurances for the administration fee, CEO Rosa Vivian Fernandez said, but patients aren’t charged any out-of-pocket fees.
Representatives from other local providers including Primary Care Associates, ICare Pharmacy, Dr. Martin Bress and Dr. Paul Percival also said they bill insurance for an administrative fee. The fee ranges depending on the insurance from $3 to $40.
Pinnacle is not vaccinating the general public as of March 18, but has partnered with Grower-Shipper Association of Central California and San Benito Health Foundation to provide onsite vaccination services for agricultural workers.
At those clinics, Alvero said the employers, typically the larger ones, opt to pay for onsite services because it saves them labor time. While the employer pays for the onsite service, it also has the option to pay administrative fees directly or go through its insurance.
While those local providers do bill insurance, San Benito County Public Information Officer David Westrick said the San Benito County Health and Human Services Agency follows state and federal law and does not charge an administrative fee or bill insurance companies for COVID-19 vaccinations.
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