CMS Sets Medicare Reimbursement Rate for COVID-19 Vaccine

A new interim final rule with comment period ensures Medicare reimbursement for the administration of a COVID-19 vaccine and provider use of innovative treatments for the novel coronavirus.

The rule released last night states that Medicare will pay providers $28.39 for the administration of a single-dose COVID-19 vaccine. In the event an approved COVID-19 vaccine requires multiple doses, CMS will reimburse providers $16.94 for the initial doses and $28.39 for the administration of the final dose in the series.

The reimbursement rate will be available under Medicare Part B unless the patient is an inpatient. CMS is working with the American Medical Association (AMA) to finalize billing codes for the use of a COVID-19 vaccine.

In the rule, the federal agency also required Medicare, Medicare Advantage, Medicaid, and most private plans to waive cost-sharing for an approved vaccine, while ensuring providers will be reimbursed via the Provider Relief Fund for administering vaccines to the uninsured.

In addition to reimbursement for vaccine administration, the final rule also ensures providers will receive reimbursement for the use of new and innovative COVID-19 treatments.

The rule, for example, creates the New COVID-19 Treatments Add-On Payment (NCTAP) under the Inpatient Prospective Payment System.

COVID-19 hospitalizations that involve the use of certain new products authorized or approved to treat the virus will qualify for the enhanced payment, which will be the lesser of 65 percent of the operating outlier threshold for the claim or 65 percent of the cost of a COVID-19 stay beyond the operating Medicare payment, including the 20 percent add-on payment for COVID-19 hospitalizations authorized by the CARES Act.

CMS also ensures Medicare reimbursement for the use of novel treatments in the outpatient setting.

The final rule makes changes to the Outpatient Prospective Payment System to exclude FDA-authorized or -approved COVID-19 drugs and biologicals from being packaged into Comprehensive Ambulatory Payment Classification (C-APC) payments when the treatments are billed on the same claims as a primary C-APC service.

Instead, Medicare will reimburse hospitals separately for the use of the drugs and biologicals.

There are currently five drug and biological products with emergency use authorizations. FDA also recently approved remesdivir as the first COVID-19 treatment in the hospital setting.

Both inpatient and outpatient reimbursement changes will only last for the duration of the COVID-19 public health emergency and come with some strings attached. The final rule also addresses price transparency and surprise billing.  

CMS is requiring all providers who furnish COVID-19 diagnostic tests to publicize their cash prices online. Providers who are non-compliant could face civil monetary penalties, the agency warns in the rule.

The rule also states that out-of-network rates for patients who are vaccinated under private plans cannot be “unreasonably low” and stakeholders should use Medicare reimbursement rates as a potential benchmark for out-of-network rates.

Other provisions in the final rule include an extension of Performance Year 5 for the Comprehensive Care for Joint Replacement model and new flexibilities in the public notice requirements and post-award public participation requirements for a State Innovation Waiver under Section 1332.

Accompanying the final rule are also three toolkits for state Medicare agencies, providers who administer vaccines, and health plans. The toolkits address issues related to access, billing and payment, and coverage of a safe and effective vaccine.

CMS Administrator Seema Verma anticipates the Medicare reimbursement plan to support the administration’s distribution of a safe and effective COVID-19 vaccine when it becomes available.

“As Operation Warp Speed nears its goal of delivering the vaccine in record time, CMS is acting now to remove bureaucratic barriers while ensuring that states, providers and health plans have the information and direction they need to ensure broad vaccine access and coverage for all Americans,” Verma said in an announcement.

To view the complete final rule, click here.

FAQs on billing COVID-19 treatments can also be found here.