COVID-19 vaccines must be covered at no cost, CMS says

The Centers for Medicare and Medicaid Services is mandating that all Americans have access to a COVID-19 vaccine, when it becomes available, at no out-of-pocket cost. 

The agency's interim final rule makes clear that private insurers must cover the vaccine at no charge to beneficiaries. Insurers are prohibited from charging administration costs of the vaccine, CMS Administrator Seema Verma said Wednesday.

"Balance billing is strictly prohibited," she said.

Medicare Advantage beneficiaries also pay nothing for COVID-19 vaccines and their copayment/coinsurance and deductible are waived.

Private insurers must cover the vaccine without cost sharing from both in and out-of-network providers during the course of the public health emergency.

The federal government is paying for the actual cost of the vaccine.

The Provider Relief Fund will pay for the administration cost of the vaccine for the uninsured, Verma said.

In Medicare, CMS is reimbursing providers $17 for the first vaccine and $28 for the second. If the patient is an inpatient, the hospital bills Medicare Part A; otherwise vaccine billing is covered under Medicare Part B.

CMS is working with the American Medical Association on billing codes, Verma said.

CMS is reimbursing for the vaccine, at a total cost of $2.6 billion if everyone in the Medicare program got vaccinated, Verma said.

WHY THIS MATTERS

Matt Eyles, president and CEO of America's Health Insurance Plans said Wednesday, "Health insurance providers will be working to swiftly implement this rule in their operations. And, health insurance providers will continue to work with federal, state and local leaders to provide our expertise and resources to ensure Americans get their COVID-19 vaccines."

AHIP applauds the Administration for making sure that all Americans can get vaccinated with no patient costs, and we thank them for ensuring that the vaccine will be administered at an affordable price, Eyles said. 
 
However, he said, "We look forward to submitting our comments on this important interim final rule."

For hospitals and physicians, any provider that performs a COVID-19 diagnostic test must post their cash prices online. Providers that are non-compliant may face civil monetary penalties of up to $300 a day.

THERAPEUTICS

CMS also announced changes to Medicare payment for therapeutics.

Usually, hospitals get a fixed payment for inpatient services. Under the new rule, hospitals may apply for outlier payments when they treat patients with new therapeutics approved for COVID-19, even if their costs for providing the treatment do not reach the $30,000 threshold.

Medicare will pay for an additional 65% of the cost provided for inpatient care when treatment cost exceeds payments up to $30,000.

"We are bridging the gap between traditional payment and outlier payment," Verma said.

THE LARGER TREND

This is the fourth interim final rule issued during the public health emergency.

Under normal circumstances, rules like this take about a year, Verma said.

Vaccine approval by the FDA will "mark the beginning of the end of the pandemic," Verma said.

There are currently several vaccine candidates in Phase 3 clinical trials. 

ON THE RECORD

CMS Administrator Seema Verma said, "As Operation Warp Speed nears its goal of delivering the vaccine in record time, CMS is acting now to remove bureaucratic barriers while ensuring that states, providers and health plans have the information and direction they need to ensure broad vaccine access and coverage for all Americans."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com