Biden-Harris Administration Increases Medicare Payment for Life-Saving COVID-19 Vaccine
On March 15, CMS increased the Medicare payment amount for administering the COVID-19 vaccine. This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff. At a time when vaccine supply is growing, CMS is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.
Effective for COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies, and many other immunizers will be $40 to administer each dose of a COVID-19 vaccine. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses. The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.
These updates to the Medicare payment rate for COVID-19 vaccine administration reflect new information about the costs involved in administering the vaccine for different types of providers and suppliers, and the additional resources necessary to ensure the vaccine is administered safely and appropriately.
CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare, or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.
Coverage of COVID-19 Vaccines:
As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:
Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance, or deductible.
Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.
Medicaid: State Medicaid and Children’s Health Insurance Program agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the Public Health Emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit.
Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost sharing during the PHE. Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates.
Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).
- Medicare COVID-19 Vaccine Shot Payment webpage: Payment for COVID-19 vaccine administration, including a list of billing codes, payment allowances, and effective dates
- CDC COVID-19 Vaccination Program Provider Requirements and Support webpage: How the COVID-19 vaccine is provided at 100% no cost to recipients
- HRSA COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured webpage
NEW COVID-19 Vaccine Guidance and Resources for Partners during the Pandemic
As COVID-19 vaccines are becoming more available across the country, CMS is taking action to protect the health and safety of our nation’s patients and providers and keeping you updated on the latest COVID-19 resources from HHS, CDC and CMS.
With information coming from many different sources, CMS has compiled resources and materials to help you share important and relevant information on the COVID-19 vaccine with the people that you serve. You can find these and more resources on the COVID-19 Partner Resources Page and the HHS COVID Education Campaign page. We look forward to partnering with you to promote vaccine safety and encourage our beneficiaries to get vaccinated when they have the opportunity. For more information visit the CMS COVID-19 Policies and Guidance page.
COVID-19 Snapshot of New COVID-19 Vaccine Information
CMS, CDC and HHS have released new guidance and resources related to the COVID-19 vaccine to serve our beneficiaries. This important information is highlighted below for our partners:
- CMS released Nursing Home Guidance with Revised Visitation Recommendations with information for nursing homes to safely expand visitation options during the COVID-19 pandemic public health emergency (PHE). According to the updated guidance, facilities should allow responsible indoor visitation at all times and for all residents, regardless of vaccination status of the resident, or visitor, unless certain scenarios arise that would limit visitation. For more information, see the Press Release, Fact Sheet and new Guidance. Please share the visiting nursing home infographic.
- CDC released new guidance, When You’ve Been Fully Vaccinated, which is the first interim recommendations for people who are fully vaccinated with guidance for visiting with others in private settings. Here’s some messaging you can share with your consumers:
- If you’ve been fully vaccinated:
- You can gather indoors with fully vaccinated people without wearing a mask.
- You can gather indoors with unvaccinated people from one other household (for example, visiting with relatives who all live together) without masks, unless any of those people or anyone they live with has an increased risk for severe illness from COVID-19.
- If you’ve been around someone who has COVID-19, you do not need to stay away from others or get tested unless you have symptoms.
- However, if you live in a group setting (like a correctional or detention facility or group home) and are around someone who has COVID-19, you should still stay away from others for 14 days and get tested, even if you don’t have symptoms.
- Fully vaccinated people can visit indoors without wearing masks or physical distancing with other fully vaccinated people or with unvaccinated people from a single household who are at low risk for severe COVID-19. They should continue to wear masks and physically distance when in public or with unvaccinated people at high risk.
- You should still take steps to protect yourself and others in many situations, like wearing a mask, staying at least 6 feet apart from others, and avoiding crowds and poorly ventilated spaces.
- For more information, see the CDC Information for Consumers page and the Science Brief.
- The CMS Office of Minority Health has developed a COVID-19 Vaccine Resources website for vulnerable populations to include many Federal resources organized for partners, health care professionals and consumers. The new website includes links to many federal resources in multiple languages to assist organizations who work with those most vulnerable—such as older adults, those with underlying medical conditions, racial and ethnic minorities, rural communities, and people with disabilities. Some resources include:
- COVID-19 Resources on Vulnerable Populations for Consumers and Patients including the From Coverage to Care COVID-19 Resources with fact sheets in 8 languages with tips to help people protect themselves during COVID-19, understand what health services are covered, and get health care services from home;
- Links to the CDC Vaccines Webpages in Spanish, Chinese, Vietnamese, and Korean.
- The FDA COVID-19 vaccine information in multiple languages, including the Moderna COVID-19 Vaccine Fact Sheets for Recipients and Caregivers in Multiple Languages and the Pfizer-BioNTech COVID-19 Vaccine Fact Sheets for Recipients and Caregivers in Multiple Languages.
- For additional vaccine resources, visit: go.cms.gov/omhcovid19vaccine.
- HHS recently announced Funding for Health Literacy Projects in Underserved Populations, dedicating $250 million to encourage COVID-19 safety and vaccination among underserved populations. The Office of the Assistant Secretary for Health announced March 8th that funding will support approximately 30 health literacy projects in urban communities and 43 projects in rural communities for two years. Cities, counties, parishes and other subdivisions, which will team up with community-based organizations, may apply for funding through the Office of Minority Health until April 20, 2021.
If you have any questions regarding the COVID-19 vaccine information, please e-mail us at: Partnership@cms.hhs.gov