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CMS releases plans for COVID-19 Vaccine Administration, Payment and Coverage

Posted Monday, November 2, 2020

CMS, under the direction of the Trump Administration, announced their preliminary plans to ensure that all Americans have access to the COVID-19 vaccine, when it becomes available. In preparation for seniors to have access to the vaccine, CMS has released an Interim Final Rule with comment period on October 29, 2020. Included in the Interim Final Rule (IFC):

  • Any vaccine that receives FDA authorization will be covered under Medicare (through emergency use authorization or Biologics license application) as a preventative vaccine, at no cost to beneficiaries
  • Enacts part of the CARES Act, ensuring coverage by most private health insurance plans without cost sharing from in and out-of-network providers
  • Hospitals would qualify for additional payments when treating patients with new approved/authorized COVID-19 treatments
  • CMS released guidance preparing hospitals to bill for outpatient administration of monoclonal antibody product, in the event one is approved
  • Any provider performing a COVID-19 Diagnostic test is required to post their cash prices online

In addition to the IFC, CMS issued three toolkits for:

  • State Medicaid Agencies
  • Providers who will administer the vaccine
  • Health Insurance plans

The toolkits address access, billing and payment, and coverage, to prepare the health care system to successfully administer the vaccine when available.

Additionally, to increase the number of providers available to administer the COVID-19 vaccine to Medicare beneficiaries, new providers are now able to enroll as “Medicare mass immunizers” through an expedited 24-hour process.

Providers will receive the COVID-19 vaccine, free from the federal government. As a condition, providers are prohibited from charging consumers for administering the vaccine.

  • Medicare: Medicare beneficiaries pay nothing for the COVId-19 vaccine, and copayment/coinsurance and deductible are waived.
  • Medicare Advantage (MA): Medicare will pay directly for the COVID-19 vaccine and administration, for beneficiaries enrolled in MA plans For calendar year 2020 and 2021. MA plans are not responsible to reimburse providers for administering the vaccine. MA beneficiaries will pay nothing for COVID-19 vaccines and copayment/coinsurance and deductible is waived.
  • Medicaid: State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for most beneficiaries, during the public health emergency. Following the PHE, states may need to evaluate cost sharing policies, and submit state plan amendments as needed.
  • Private Plans: CMS and the Departments of Labor and Treasury, are requiring most private health plans to cover a COVID-19 vaccine and its administration (both in and out of network) with no cost sharing.
  • Uninsured: Providers will receive reimbursement for administering the COVID-19 vaccine to individuals who are uninsured, through the Provider Relief Fund.


CMS Toolkits also addresses billing and payment of the COVID-19 vaccine:

  • Once FDA approves COVID-19 vaccine, CMS will identify the specific vaccine codes and administration codes, for Medicare payment, and guidance for tracking.
  • CMS release Medicare payment rates for COVID-19 vaccine administration, which will be geographically adjusted:
    • Single dose vaccine rate: $28.39
    • Vaccine requiring two or more doses: $16.94 and $28.39 for the administration of the final dose
    • Medicare beneficiaries, those in Original Medicare or enrolled in Medicare Advantage, will be able to get the vaccine at no cost.
  • CMS encouraged state policymakers to use the strategy set for Medicare as a model when developing their vaccine administration and payment plan for the Medicaid, CHIP, Basic Health Program and private plans.


CMS Resources

The IFC (CMS-9912-IFC) is scheduled to display at the Federal Register as soon as possible with an immediate effective date, and a 30-day comment period. It can be downloaded from the Federal Register at: https://www.cms.gov/files/document/covid-vax-ifc-4.pdf 

Additional information on this IFC can be found in the fact sheet here: https://www.cms.gov/newsroom/fact-sheets/fourth-covid-19-interim-final-rule-comment-period-ifc-4 

The COVID-19 vaccine resources for providers, health plans and State Medicaid programs can be found here: https://www.cms.gov/covidvax 

The FAQs on billing for therapeutics can be found here: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf