CMS expands Medicare payments for at-home COVID-19 vaccinations

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In an effort to increase access to vaccinations, the Centers for Medicare and Medicaid Services has stipulated that healthcare providers can now receive additional payments for administering vaccines to multiple residents in a home or communal setting, with an eye toward Medicare beneficiaries who have difficulty leaving their homes.

The announcement aims to further boost the administration of COVID-19 vaccination – including second and third doses – in smaller group homes, assisted living facilities and other group living situations, by allowing vaccine providers to receive the increased payment up to five times when fewer than 10 Medicare beneficiaries get the vaccine on the same day in the same home or communal setting. 

The policy is meant to ensure that at-risk patients in smaller settings have the same opportunities as others to receive the vaccination.

While many Medicare beneficiaries are able to receive a COVID-19 vaccine at a retail pharmacy or from a healthcare provider, some have difficulty leaving their homes or cannot easily access vaccination in these settings, CMS said. These people are often at-risk patients who could require complex care if they contracted COVID-19 and needed to be hospitalized. 

To address this, Medicare previously increased the total payment amount for at-home vaccination from about $40 to about $75 per vaccine dose, in certain circumstances.

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 policy seeks to address these challenges.

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, is geographically adjusted based on where the service is furnished.

WHAT'S THE IMPACT?

The federal government is providing the COVID-19 vaccine free of charge or with no cost-sharing for Medicare beneficiaries. 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 has provided some information for providers. For instance, beneficiaries with Medicare pay nothing for COVID-19 vaccines or their administration, and there is no applicable copayment, coinsurance or deductible.

Also, Medicaid and CHIP agencies must cover COVID-19 vaccine administration with no cost sharing for nearly all beneficiaries during the public health emergency and, generally, for more than a year after it ends.

For the limited number of Medicaid beneficiaries who are not eligible for this coverage – and don't receive it through other coverage they might have – providers can submit claims for reimbursement for administering the vaccine to underinsured individuals through the COVID-19 Coverage Assistance Fund, administered by the Health Resources and Services Administration.

The vaccine is free for people enrolled in most private health plans. The COVID-19 vaccines and the administration are 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 compared to prevailing market rates, and the rules reference using the Medicare payment rates as a potential guideline for insurance companies.

THE LARGER TREND 

Under the American Rescue Plan Act of 2021, signed by President Biden on March 11, the federal matching percentage for state Medicaid and CHIP expenditures on COVID-19 vaccine administration is 100% as of April 1, and will remain 100% for more than a year after the PHE ends. The ARP also expands coverage of vaccine administration under Medicaid and CHIP to additional eligibility groups.

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com