On October 28, the Centers for Medicare and Medicaid Services (CMS) released a comprehensive plan to remove regulatory barriers and ensure consistent coverage and payment for the administration of an eventual COVID-19 vaccine. CMS released a set of toolkits for providers, states and insurers to help the health care system prepare to administer the vaccine once it is available. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate reimbursement for administering the vaccine in Medicare, while making it clear to private insurers and Medicaid programs their responsibility to cover the vaccine at no charge to beneficiaries. Additionally, to ensure broad access to the COVID-19 vaccine, CMS released an Interim Final Rule with Comment Period (IFC) that states that any vaccine that receives Food and Drug Administration (FDA) authorization, either through an Emergency Use Authorization (EUA) or licensed under a Biologics License Application (BLA), will be covered under Medicare as a preventive vaccine at no cost to beneficiaries. The IFC also implements provisions to ensure coverage of a COVID-19 vaccine by most private health insurance plans without cost sharing from both in and out-of-network providers during the course of the public health emergency (PHE).
The CMS toolkits for state Medicaid agencies, providers who will administer the vaccine, and health insurance plans address issues related to access, billing and payment, and coverage. Several key highlights include:
Increasing Access to Vaccines for Medicare & Medicaid Beneficiaries
The toolkits give health care providers not currently enrolled in Medicare the information needed to administer and bill vaccines to Medicare patients. CMS is working to increase the number of providers able to administer a COVID-19 vaccine to Medicare beneficiaries, and new providers are now able to enroll as a “Medicare mass immunizers” through an expedited 24-hour process. CMS is also making it easier for newly enrolled Medicare providers to also enroll in state Medicaid programs to support state administration of vaccines for Medicaid recipients.
As a condition of receiving free COVID-19 vaccines from the federal government, providers will be prohibited from charging consumers for administration of the vaccine. The toolkits provide specific information for Medicare, Medicare Advantage, Medicaid, private plans, and uninsured individuals.
Billing and Payment
The toolkits address issues related to billing and payment. After a vaccine for COVID-19 is approved, CMS will identify the specific vaccine codes, by dose if necessary, and specific vaccine administration codes for each dose for Medicare payment.
CMS also released new Medicare payment rates for COVID-19 vaccine administration. The Medicare payment rates will be $28.39 to administer single-dose vaccines. For a COVID-19 vaccine requiring a series of two or more doses, the initial dose(s) administration payment rate will be $16.94, and $28.39 for the administration of the final dose in the series. These rates will be geographically adjusted and recognize the costs involved in administering the vaccine, including the additional resources involved with required public health reporting, conducting important outreach and patient education, and spending additional time with patients answering any questions they may have about the vaccine. Medicare beneficiaries, those in Original Medicare or enrolled in Medicare Advantage, will be able to get the vaccine at no cost. Additionally, CMS is encouraging state policymakers and other private insurance agencies to utilize the information on the Medicare reimbursement strategy to develop their vaccine administration payment plan in the Medicaid program, CHIP, the Basic Health Program (BHP), and private plans. Using the Medicare strategy as a model would allow states to match federal efforts in successfully administering the full vaccine to the most vulnerable populations.
For additional information and details, access the below CMS guidance and resources:
- CMS COVID-19 Vaccine Policies and Guidance
- Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration and Cost Sharing under Medicaid, the Children’s Health Insurance Program, and Basic Health Program
- Fourth COVID-19 Interim Final Rule with Comment Period (IFC-4)
- COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing