COVID-19 vaccine is free, yet some are getting bills. Doctors worry this is slowing immunization.

Martin Gola knew the COVID-19 vaccine was supposed to be free. So he was surprised when, in July, he received a $32 bill from Nazareth Hospital in Northeast Philadelphia, where he’d gotten the two-dose Moderna vaccine. A few days later came another bill, this one for $79.

The 59-year-old Philadelphia resident ignored the bills, but he got worried when weeks later Trinity Health, which owns Nazareth, called to collect on his overdue account.

“I said: ‘It’s for COVID, it’s a free shot. I’m not paying that bill.’ They didn’t say anything and we hung up,” Gola recalled.

But the call rattled him. He started to worry if — mistake or not — the bill would affect his credit rating and considered paying it to eliminate the possibility.

The U.S. government bulk-purchased millions of doses of COVID-19 vaccines to ensure the shots would be free for everyone, regardless of whether they have health insurance, are visiting the United States, or are undocumented. Providers are not allowed to bill patients for the vaccine itself or costs associated with administering it.

While actually receiving a bill for the vaccine appears to be rare, many more people believe they may be charged for the shot and so don’t get vaccinated.

“There’s this general skepticism about our health-care system that is probably well warranted in many circumstances,” said Cynthia Cox, a vice president at the Kaiser Family Foundation, which has been tracking COVID-19 vaccination. “But this is really a situation where there are no ifs, ands, or buts about it…. No one should be paying for the vaccine. Absolutely no one.”

But that has proven to be a hard sell to people who know that very little comes for free in American health care.

The cost of health care is infamously mysterious in the United States. People rarely know how much a service will cost — or how much of it will be covered by insurance — until they get the bill. Or, more accurately, until they get a few bills since what they actually owe can change once an insurer reviews the charges. Even procedures that are supposed to be covered in full by insurance can lead to surprise bills, for instance when an out-of-network anesthesiologist assists an in-network gastroenterologist during a routine colonoscopy.

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In an April survey by the Kaiser Family Foundation, 32% of people who had not gotten vaccinated said they were worried they may have to pay for the shot, though this fear was the primary barrier for a much smaller group, 5%, according to a follow-up survey in June.

While the vaccine itself has been prepaid for by the federal government, there is also a cost to storing and administering the doses.

Under federal law, providers can bill private health insurance companies, Medicare, and Medicaid for administration costs, and they are required to pay — which is why people are asked for their insurance card when they go to get vaccinated.

Providers can bill a federal fund to recoup the cost of vaccinating individuals who are uninsured.

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Collecting insurance information also helps insurance companies track who has gotten vaccinated, so insurers can better target outreach efforts, said Chris Regal, director of clinical innovations at the Association of Health Insurance Plans. Insurance companies have a vested interest in getting people vaccinated because the cost of the shot is far less than the cost of a hospitalization for COVID-19 or the ongoing medical needs for people who develop long COVID.

“The impact this has downstream is astronomical,” Regal said. “Eighteen dollars for a vaccine administration or the effects of long COVID — that’s a pretty bad situation to put anyone in from a health perspective and a cost perspective.”

People who encounter a billing problem often turn first to their insurer and might not think to report the problem to their state insurance department.

Insurance regulators in Pennsylvania and New Jersey encouraged anyone who gets billed for ar COVID-19 vaccine to report it, so they can investigate and prevent others from being billed.

Report problems in Pennsylvania online, at www.insurance.pa.gov. New Jersey residents can call the consumer hotline (1-800-446-7467) or file a complaint through the department’s website, www.dobi.nj.gov

People who are uninsured are even more sensitive to health-care costs. They also may be more vulnerable to COVID-19, since data suggest the uninsured are more likely to have uncontrolled chronic health conditions, such as diabetes and lung disease, that can make a COVID-19 infection especially severe.

Fear of being billed for the vaccine is a common concern among undocumented immigrants and migrant workers, who are not offered employer-based health plans, are not eligible for Medicaid, and can’t afford to buy private insurance, said Melissa Pluguez, the medical director for Unidos Contra COVID, a regional organization working to increase vaccination rates in Latino communities.

“They come up with the raised eyebrow of, ‘I don’t have insurance. I don’t have anything. Is this going to cost me?’” said Pluguez, a nurse-practitioner. “If you’re not billing me, who do you bill and where does my name and address go? It brings up this very heightened level of fear, not only that they’re going to get billed, but that their name is going to some government agency.”

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Rumors that prevent people from getting vaccinated can be difficult to overcome in the Latino community Unidos Contra COVID serves because many people do not speak English and do not feel comfortable going to a pharmacy to ask for more information, Pluguez said.

The group’s clients have also expressed concern that the vaccine includes a computer chip to allow the government to track them. Others have heard the vaccine will make them sterile — a fear rooted in a history of forced sterilization by the government, including a program in Puerto Rico that sterilized a third of Puerto Rico’s female population between 1930 and 1970.

Unidos Contra COVID has had success getting people vaccinated by reaching out to trusted community leaders, such as churches, and having individual conversations with patients. Pluguez said she sometimes shows people the vial of liquid and syringe, so they can see it does not contain a microchip.

But overcoming misinformation is difficult when people hear stories like Gola’s.

Trinity Health did not respond to a request for comment.

Jolene Calla, a vice president at the Hospital and Healthsystem Association of Pennsylvania, said that she could not speak to Trinity Health’s operations but that in general, cases of people being billed for the vaccine are “extremely rare.”

“Right now the push is to reach anyone who’s not vaccinated,” she said. “Funding should be no barrier to that.”

After the call from Trinity, Gola contacted his insurance company, which assured him he didn’t owe anything. He later received an explanation of benefits showing his plan had paid.

He’s glad he didn’t end up paying the bill — though he suspects others have.

The Philadelphia Inquirer is one of more than 20 news organizations producing Broke in Philly, a collaborative reporting project on solutions to poverty and the city’s push toward economic justice. See all of our reporting at brokeinphilly.org.