By: Dean Viskovich
On November 13, 2020 Centers for Medicare and Medicaid Services (CMS) announced that all Americans will have access to the COVID-19 vaccine at no cost. CMS has clearly communicated to private insurers, Medicaid programs and Medicare that it is their responsibility to cover the vaccine at no charge to beneficiaries. CMS states that Operation Warp Speed ensures that States, provider’s and health plans have the information and direction they need to ensure broad vaccine access and coverages for all. As a condition of receiving free COVID-19 vaccines from the federal government, providers will be prohibited from charging consumers for administration of the vaccine.
Beneficiaries with Medicare will not pay anything for the COVID-19 vaccine and their coinsurance/copayment and deductible amounts will be waived. In 2021, for Medicare Advantage beneficiaries, Medicare will pay directly for the vaccine and its administration for those enrolled in MA plans. MA plans are not responsible for reimbursing providers to administer the vaccine. MA beneficiaries do not pay for the vaccine and copayment/coinsurance and deductibles are waived.
State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for beneficiaries during the public health emergency. After the public health emergency, states may have to evaluate cost sharing policies and submit an updated plan if needed.
CMS, the Department of Labor and the Treasury, require most private health plans and issuers cover a COVID-19 vaccine and its administration, for both in-network and out-of-network with no cost sharing. Providers will be able to be reimbursed for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).
The AMA published updated CPT codes for the COVID-19 vaccine. Three COVID-19 vaccines, Pfizer, Moderna and AstraZeneca, have been assigned to new CPT codes (91300, 91301, 91302) and six new codes are added (0001A, 0002A, 0011A, 0012A, 0021A, 0022A) for the administration of these vaccines. The effective date for the updated CPT codes is December 11, 2020.
The Medicare payment rate for a single dose COVID-19 vaccine administration is $28.39. A COVID-19 vaccine requiring a series of two or more doses rate of reimbursement is $16.94 for the initial dose and $28.39 for the administration of the final dose in the series. CMS has directed providers not to bill for the product since it is being received for free and the vaccine itself is not eligible for reimbursement, but the administration of the vaccine is reimbursable.