Providers that administer the COVID-19 vaccine are getting a payment bump from CMS

Providers will receive an increase in the Medicare payment rate for administering the COVID-19 vaccine, CMS announced Monday. The goal of the payment boost is to “support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day,” the agency stated in a news release.

Effective March 15, providers will receive $40 per dose administered, an increase from approximately $28 for single-dose vaccines. For two-dose vaccines, the increase is from $45 to $80.

CMS notes that the payment rate may vary based on the type of entity (e.g., hospital, physician’s office, pharmacy) that administers the vaccine and is subject to geographical adjustments.

“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,” the news release states.

CMS noted that it has updated its toolkits for healthcare stakeholders that play a role in vaccine administration: “These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.”

Requirements for different payers

The following information from the CMS news release details how vaccine-related requirements apply to different payers:

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

Medicare Advantage (MA). For CY20 and CY21, Medicare will pay providers directly for procuring the COVID-19 vaccine (if they do not receive it for free) and administering it to beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. MA enrollees 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 until at least one year after the end of the public health emergency (PHE). The recently signed American Rescue Plan establishes that COVID-19 vaccine administration will be fully federally funded. The legislation also provides for an expansion of eligibility for vaccine administration coverage.

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 PHE. Current regulations establish that out-of-network rates must be reasonable compared with prevailing market rates, withMedicare payment rates referenced as a potential guideline.

In light of the increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable compared with prevailing market rates, the news release states.

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.

The CDC has additional information on vaccination requirements and support for healthcare providers.