CMS Boosts Medicare Reimbursement for COVID Vaccine Administration  

As vaccination rates slowly rise, federal officials are urging the pace to quicken.

As COVID-19 vaccination rates slowly creep higher in jurisdictions across the country, federal officials are seeking to give the numbers a shot in the arm.

The Centers for Medicare & Medicaid Services (CMS) announced Monday that this includes increasing the Medicare payment amount for administering the three currently available vaccines, a move it said would “support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff.”

Effective for COVID-19 vaccines administered on or after March 15, the national average Medicare payment rate for physicians, hospitals, pharmacies, and many other immunizers will rise from approximately $28 to $40 for the administration of single-dose vaccines, while going from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses – considerable increases of about 43 and 77 percent, respectively. The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted. 

“These updates to the Medicare payment rate for COVID-19 vaccine administration reflect new information about the costs involved in administering the vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately,” CMS said in a press release announcing the reimbursement hikes. “CMS is (also) updating the set of toolkits for providers, states, and insurers to help the healthcare system swiftly administer the vaccine with these new Medicare payment rates.”

Two-dose vaccines developed by Moderna and Pfizer were among the first to be distributed nationwide, while Johnson & Johnson’s single-dose vaccine likewise earned emergency use authorization (EUA) from the U.S. Food and Drug Administration (FDA) late last month. Since vaccine distribution began in the U.S. on Dec. 14, 2020, more than 107 million doses have been administered, reaching 21 percent of the total U.S. population, according to federal data collected by the Centers for Disease Control and Prevention (CDC). NPR recently reported that providers across the country are currently administering over 2.3 million shots a day, with that figure rising over 4 million on particularly active days.

As a condition of receiving free COVID-19 vaccines from the federal government, officials noted in the CMS press release, providers are prohibited from charging patients any amount for administration of the vaccine.

Monday’s announcement included the following program-specific beneficiary information for COVID vaccination:

Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines, and there is no applicable copayment, coinsurance, or deductible.

Medicare Advantage (MA): For the 2020 and 2021 calendar years, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost sharing for COVID-19 vaccines.

Medicaid: State Medicaid and Children’s Health Insurance Program (CHIP) agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the public health emergency (PHE), and at least one year after it ends. Through the American Rescue Plan Act signed into law last week, the COVID vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit, available online at https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf.  

Private Plans: CMS, along with the U.S. departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing during the PHE. Current regulations provide that out-of-network rates must be “reasonable, as compared to prevailing market rates,” and reference the Medicare reimbursement rates as a potential guideline for insurance companies.

Uninsured: For the uninsured, providers may submit claims for reimbursement through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

More information on Medicare payment for COVID-19 vaccine administration – including a list of billing codes, payment allowances, and effective dates – is available online at https://www.cms.gov/medicare/covid-19/medicare-covid-19-vaccine-shot-payment.

More information regarding the CDC COVID-19 Vaccination Program Provider Requirements, and how the COVID-19 vaccine is provided at no cost to recipients, is available at: https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html.

The global COVID-19 pandemic has sickened more than 120 million people worldwide, killing 2.67 million, including more than 30 million cases and nearly 550,000 deaths in the U.S. alone.