CMS Releases Vaccine Coverage Plan, Medicare Reimbursement Rate

CMS has released its Medicare reimbursement rate and official coverage strategy for the coronavirus vaccine when one is approved.

For more coronavirus updates, visit our resource page, updated twice daily by Xtelligent Healthcare Media.

CMS has submitted an interim final rule for comment which would classify any drug approved by the Food and Drug Administration as a preventive vaccine. This would ensure that it should be covered in full by Medicare.

“The Medicare payment rates will be $28.39 to administer single-dose vaccines,” the press release explains. “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.”

The rates are subject to changes based on geographical location and administration costs including public health reporting.

Medicare Advantage plans will not be responsible for reimbursing providers for members’ coronavirus vaccines. Medicare will cover Medicare Advantage members’ vaccinations in full for calendar years 2020 and 2021.

Medicaid programs and the Children’s Health Insurance Program (CHIP) must cover coronavirus vaccination at no cost for the duration of the public health emergency. States can re-evaluate their vaccination coverage policy after the public health emergency lifts and alter their approach through a state plan amendment.

For private payers, the interim final rule enacts the CARES Act directives that, for the duration of the public health emergency, private health plans must cover the vaccine without cost-sharing for both in- and out-of-network providers. Out-of-network rates must be at a reasonable rate and may be based on CMS reimbursement rates.

“For individuals who are uninsured, providers will be able to be reimbursed for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA),” the press release states.

Through the rule, states receive flexibility around Medicaid enrollment and around strategies for handling Medicaid program finances as they receive the temporary boost in federal medical assistance percentage (FMAP).

Price transparency remains high priority to CMS throughout these efforts. Providers are instructed to post their coronavirus diagnostic testing prices online or risk a financial penalty.

The rule includes hospital-specific directives and expands on previous additional payments opportunities for hospitals.

Along with the details of vaccine distribution, CMS has released toolkits for providers, states, and payers.

The toolkits’ aim to help providers attain higher vaccine administration rates and guide them through Medicare reimbursement. The CMS resources also reinforce that states and payers are responsible for covering the vaccine.