CMS establishes $28 Medicare rate for eventual COVID-19 vaccine

October 30, 2020

In an effort to be prepared to hit the ground running once a COVID-19 vaccine is made publicly available, CMS released an interim final rule with comment period late Thursday that sets the Medicare payment rate for administering a single dose at $28.39.

In the event an approved COVID-19 vaccine requires multiple doses, CMS said it will reimburse providers $16.94 for the initial doses and $28.39 for the administration of the final dose in the series.

CPT codes for vaccine administration have not yet been published, however, CMS said it is working with the American Medical Association to establish those codes. The reimbursement will be available under Medicare Part B unless the patient is an inpatient.

CMS also clarified in the rule that the vaccine must be made available to all patients at no cost, requiring almost all plans to waive any cost-sharing requirements and preventing providers from balance-billing for the service. The rule states that providers will be reimbursed via the HHS Provider Relief Fund when treating uninsured patients.

The rule also aims to incentivize providers for utilizing new COVID-19 treatments, in part through the creation of a new COVID-19 Treatments Add-On Payment (NCTAP) for the Inpatient Prospective Payment System (IPPS).

COVID-19 hospitalizations that involve the use of certain new products authorized or approved to treat the virus will qualify for the enhanced payment, which will be the lesser of 65 percent of the operating outlier threshold for the claim or 65 percent of the cost of a COVID-19 stay beyond the operating Medicare payment, including the 20 percent add-on payment for COVID-19 hospitalizations authorized by the CARES Act.

CMS said Medicare reimbursement for utilizing novel treatments in an outpatient setting will also be available.

The final rule makes changes to the Outpatient Prospective Payment System (OPPS) to exclude FDA-authorized or -approved COVID-19 drugs and biologicals from being packaged into Comprehensive Ambulatory Payment Classification (C-APC) payments when the treatments are billed on the same claims as a primary C-APC service. Instead, Medicare will reimburse hospitals separately for the use of the drugs and biologicals.

There are currently five drug and biological products with emergency use authorizations. FDA also recently approved remesdivir as the first COVID-19 treatment in the hospital setting.

These payment changes will remain in place throughout the ongoing public health emergency.

Additionally, CMS is again reminding all providers who offer COVID-19 diagnostic tests to post their cash prices online in an easily identifiable place. Those who fail to do so could face civil monetary penalties.

The rule also states that out-of-network rates for patients who are vaccinated under private plans cannot be “unreasonably low” and stakeholders should use Medicare reimbursement rates as a potential benchmark for out-of-network rates.

If you have additional questions about these new rules, don’t hesitate to reach out to us directly for clarification at 517-486-4262.

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