CMS increasing payment for COVID-19 vaccinations

The national average payment rate will increase by about $12 for administering each dose of the vaccines.

The Centers for Medicare & Medicaid Services (CMS) is increasing the Medicare pay rate for administering COVId-19 vaccines.

According to a news release, the national average payment rate for each dose of COVID-19 vaccines administered on or after March 15 will be $40, an increase from about $28 for administering a single dose and from $45 for administering two doses. These increases are effective for physicians, hospitals, pharmacies and other immunizers and the exact payment rate for each dose administered is dependent on the type of entity that furnishes the service and geographically adjusted based on location.

CMS is also updating a set of toolkits for practices, states, and insurers to help to swiftly administer the vaccines with the new payment rates. They are designed to increase the number of providers who can administer the COVID-19 vaccines and ensuring that no patient covered by private insurance, Medicare, or Medicaid should pay cost-sharing for the administration of the vaccines, the release says.

Physicians who receive free COVID-19 vaccines from the federal government are prohibited from charging patients any amount for the shots. The aforementioned toolkits have specific information for several programs to ensure broad and consistent coverage. A portion of that information is included below:

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

Medicare Advantage (MA): For calendar years 2020 and 2021, 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 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 by President Biden on March 11, 2021, 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 at: https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf.

Private Plans: CMS, along with the 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 public health emergency (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. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.

Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).