March Madness: Double your money for COVID-19 vaccine administration
Published date: March 16, 2021
CMS has increased the Medicare payment for administering the COVID-19 vaccine for doses given on or after March 15, 2021.
The national average payment rates for physicians, hospitals, and pharmacies is now $40 to administer each vaccine resulting in $40.00 for single dose vaccines, and $80.00 for vaccines requiring two doses. (This is an increase from previous payment rates of $28.39 for single dose vaccines and $45.33 for two dose vaccines). Note: all rates are geographically adjusted.
For currently authorized vaccines, the following CPT codes should be used to bill for the administration. As the product itself is still furnished at no charge from the federal government, no codes should be reported on the claim for the vaccine product unless the provider’s billing system requires a token charge. Please note that although the payment rate is now the same for the 1st and 2nd dose of a two-dose vaccine, the codes used to report the administration are unique and should not be interchanged.
As a reminder, these vaccines are authorized under an Emergency Use Authorization (EUA), so condition code 91 should be added to the claim for any COVID-19 vaccines administered on or after February 1, 2021.
CMS has increased the reimbursement rate for COVID-19 vaccine administration to a national payment allowance of $40 per administration for any doses administered on or after March 15, 2021.
Specific codes are available to bill for each product, and for products which require two doses there are two unique codes for the first and second doses. There’s a list on website.
Don’t forget to add condition code 91 to all claims February 1, 2021 or after that indicates that these services are under an Emergency Use Authorization or EUA.
As a reminder, although product codes are available, CMS has specifically instructed that the vaccine codes should not be reported on the claim when the product is provided at no cost. However, CMS recognizes that many provider billing systems require a charge to be submitted, even when a product is provided for free or without charge and then institutional providers must report the applicable drug HCPCS code and appropriate units with a token charge of less than $1.01.
Providers cannot charge patients for the vaccine or vaccine administration when provided free from the government.
Medicare patients receive COVID-19 vaccinations with no co-pay, deductible, or co-insurance.
Medicare Advantage patients’ claims will be billed to Medicare Fee-For-Service through 2021.
State Medicaid and CHIP 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. The COVID vaccine administration will be fully federally funded by law signed by President Biden on March 11, 2021.
Some States have also provided supplemental payment for administration to Medicaid beneficiaries.
For 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 public health emergency (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.
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).