Jun 09, 2021
As part of President Biden’s commitment to increasing access to
vaccinations, the Centers for Medicare & Medicaid Services (CMS) today
announced an additional payment amount for administering in-home COVID-19 vaccinations
to Medicare beneficiaries who have difficulty leaving their homes or are
otherwise hard-to-reach. This announcement further demonstrates continued
efforts of the Biden-Harris Administration to meet people where they are and
make it as easy as possible for all Americans to get vaccinated. There
are approximately 1.6 million adults 65 or older who may
have trouble accessing COVID-19 vaccinations because they have difficulty
leaving home.
While many Medicare beneficiaries can receive a COVID-19 vaccine
at a retail pharmacy, their physician’s office, or a mass vaccination site,
some beneficiaries have great difficulty leaving their homes or face a taxing
effort getting around their communities easily to access vaccination in these
settings. To better serve this group, Medicare is incentivizing providers and
will pay an additional $35 per dose for COVID-19 vaccine administration in a
beneficiary’s home, increasing the total payment amount for at-home vaccination
from approximately $40 to approximately $75 per vaccine dose. For a two-dose
vaccine, this results in a total payment of approximately $150 for the
administration of both doses, or approximately $70 more than the current rate.
“CMS is committed to meeting the unique needs of Medicare
consumers and their communities – particularly those who are home bound or who
have trouble getting to a vaccination site. That’s why we’re acting today to
expand the availability of the COVID-19 vaccine to people with Medicare
at home,” said CMS Administrator Chiquita Brooks-Lasure. “We’re committed to
taking action wherever barriers exist and bringing the fight against the
COVID-19 pandemic to the door of older adults and other individuals covered by
Medicare who still need protection.”
Delivering COVID-19 vaccination to access-challenged and
hard-to-reach individuals poses some unique challenges, such as ensuring
appropriate vaccine storage temperatures, handling, and administration. The
Centers for Disease Control and Prevention (CDC) has outlined guidance to assist vaccinators
in overcoming these challenges. Today’s announcement now helps to address the
financial burden associated with accommodating these complications.
The additional payment amount also accounts for the clinical
time needed to monitor a beneficiary after the vaccine is administered, as well
as the upfront costs associated with administering the vaccine safely and
appropriately in a beneficiary’s home. The payment rate for administering each
dose of a COVID-19 vaccine, as well as the additional in-home payment amount,
will be geographically adjusted based on where the service is furnished.
How to Find a COVID-19 Vaccine
As today’s action demonstrates, a person’s ability to leave
their home should not be an obstacle to getting the COVID-19 vaccine. As states
and the federal government continue to break down barriers – like where
vaccines can be administered – resources for connecting communities to
vaccination options remain key. Unvaccinated individuals and those looking to
assist friends and family can:
1.
Visit vaccines.gov
(English) or vacunas.gov (Spanish) to search for vaccines nearby.
2.
Text GETVAX (438829)
for English or VACUNA (822862) for Spanish for near-instant access to details
on three vaccine sites in the local area.
3.
Call the National
COVID-19 Vaccination Assistance Hotline at 1-800-232-0233 (TTY: 1-888-720-7489)
for assistance in English and Spanish.
Coverage of COVID-19 Vaccines
The federal government is providing the COVID-19 vaccine free of
charge or with no cost-sharing for all people living in the United States. As a
condition of receiving free COVID-19 vaccines from the federal government,
vaccine providers cannot charge patients any amount for administering the
vaccine.
Because no patient can be billed for COVID-19 vaccinations, CMS
and its partners have provided a variety of information online for providers
vaccinating all Americans regardless of their insurance status:
·
Original
Medicare and Medicare Advantage: Beneficiaries with Medicare pay nothing for COVID-19
vaccines or their administration, and there is no applicable copayment,
coinsurance or deductible.
·
Medicaid
and the Children’s Health Insurance Program (CHIP): State Medicaid and CHIP agencies must cover
COVID-19 vaccine administration with no cost sharing for nearly all
beneficiaries during the COVID-19 public health emergency (PHE) and for over a
year after it ends. For the very limited number of Medicaid beneficiaries
who are not eligible for this coverage (and do not receive it through other
coverage they might have), providers may submit claims for reimbursement for
administering the COVID-19 vaccine to underinsured individuals through the
COVID-19 Coverage Assistance Fund, administered by the Health Resources and
Services Administration (HRSA), as discussed below.
Under the American Rescue Plan Act of 2021 (ARP), signed by President Biden on
March 11, 2021, the federal matching percentage for state Medicaid and CHIP
expenditures on COVID-19 vaccine administration is currently 100% (as of April
1, 2021), and will remain 100% for more than a year after the COVID-19 PHE
ends. The ARP also expands coverage of COVID-19 vaccine administration under
Medicaid and CHIP to additional eligibility groups. CMS recently updated the
Medicaid vaccine toolkit to reflect the enactment of the ARP at https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf.
·
Private
Plans: The vaccine is free
for people enrolled in private health plans and issuers COVID-19
vaccine and its administration is covered without cost sharing for most
enrollees, and such coverage must be provided both in-network and
out-of-network during the PHE. Current regulations provide that out-of-network
rates must be reasonable as compared to prevailing market rates, and the rules
reference using the Medicare payment rates as a potential guideline for
insurance companies.
In light of CMS’s increased Medicare payment rates, CMS will expect health
insurance issuers and group health plans to continue to ensure their rates are
reasonable when compared to prevailing market rates. Under the conditions of
participation in the CDC COVID-19 Vaccination Program, providers cannot charge
plan enrollees any administration fee or cost sharing, regardless of whether
the COVID-19 vaccine is administered in-network or out-of-network.
The Biden-Harris Administration is providing free access to
COVID-19 vaccines for every adult living in the United States. For individuals
who are underinsured, providers may submit claims for reimbursement
for administering the COVID-19 vaccine through the COVID-19 Coverage Assistance
Fund administered by the Health Resources and Services Administration (HRSA)
after the claim to the individual’s health plan for payment has been denied or
only partially paid. Information is available at https://www.hrsa.gov/covid19-coverage-assistance.
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). Information on the
COVID-19 Claims Reimbursement to Health Care Providers and Facilities for
Testing, Treatment, and Vaccine Administration for the Uninsured Program is
available at https://www.hrsa.gov/CovidUninsuredClaim.
More information on Medicare payment for COVID-19 vaccine
administration – including a list of billing codes, payment allowances and
effective dates – is available 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 through that
program at no cost to recipients is available at https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html.
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