WASHINGTON — Providers will be guaranteed reimbursement for any COVID-19 vaccine authorized by the FDA, as well as for the cost of administering it to Medicare beneficiaries and to the general public, the Centers for Medicare & Medicaid Services (CMS) announced in an interim final rule.
“The rule establishes that any COVID-19 vaccine receiving FDA emergency use authorization or standard approval will be covered by Part B as a preventive vaccine at no cost to Medicare beneficiaries,” CMS Administrator Seema Verma said Wednesday evening on a call with reporters. “While the federal government is paying for the vaccine, insurers — including Medicare, Medicaid, and private plans — must cover the cost of administering it,” she said.
“The rule removes any existing ambiguity surrounding Medicare’s coverage of the COVID-19 vaccine and allows us to focus on the paramount goal of ensuring that all 62 million Medicare beneficiaries can receive the vaccine from their provider of choice at no cost.”
For providers, CMS has set Medicare reimbursement for vaccine administration at $16.94 for the first dose and $28.39 for the second. (The first vaccines expected to become available require two doses; future products that need only one dose will be reimbursed at $28.39, according to CMS.)
Verma said these amounts are a little bigger than usual for vaccines because these particular products come with requirements for reporting to the CDC and Operation Warp Speed, and outreach to patients to make sure they come back for their second dose, she said. Private insurers’ and Medicaid reimbursement for vaccine administration will vary. If every senior is given a two-dose vaccine, Medicare’s bill for administration will come to about $2.6 billion, Verma said.
The 68 million enrollees in Medicaid and the Children’s Health Insurance Program (CHIP) will get the vaccine free of charge, and the rule “requires most private health insurance plans, including individual health insurance and employer health plans to provide in- and out-of-network coverage of the vaccine at no cost to their members; this represents about 200 million Americans,” she added. “In addition, providers who receive free COVID-19 vaccines from the federal government will be prohibited from charging consumers any additional cost for the administration of the vaccine beyond what their insurance covers. Surprise or balance billing for vaccine costs is strictly prohibited.” Federal funds will be used to cover vaccine costs for those without any insurance.
“We have made it very clear there will be no out-of-pocket expenses” for Medicare patients to get vaccinated, said Verma, stressing that CMS has been providing waivers to providers so they can waive any such expenses for their patients.
CMS is also hiking reimbursements to hospitals using newer COVID-19 therapies. “In Medicare, hospitals are generally reimbursed a fixed payment amount for the services they provide during an inpatient stay, even if their costs exceed that amount,” the agency said in a press release. “Under current rules, hospitals may qualify for additional ‘outlier payments,’ but only when their costs for a particular patient exceed a certain threshold. Under this [rule], hospitals would qualify for additional payments when they treat patients with innovative new products approved or authorized to treat COVID-19 to mitigate any losses they may experience from making these therapies available, even if they do not reach the current outlier threshold.”
CMS also issued three toolkits addressing vaccine administration for state Medicaid agencies, providers who will administer the vaccine, and health insurance plans. “The toolkits issued today give health care providers not currently enrolled in Medicare the information needed to administer and bill vaccines to Medicare patients,” CMS said in the release. “CMS is working to increase the number of providers that will administer a COVID-19 vaccine to Medicare beneficiaries when it becomes available, to make it as convenient as possible for America’s seniors. New providers are now able to enroll as a ‘Medicare mass immunizer’ through an expedited 24-hour process…. CMS is also making it easier for newly enrolled Medicare providers to also enroll in state Medicaid programs to support state administration of vaccines for Medicaid recipients.”
The rule is expected to be published in the Federal Register “as soon as possible” and will have a 30-day comment period, CMS said.