Doctor giving a senior woman a vaccination

Providers offering the shot to multiple residents in one home setting or communal setting will now be eligible for multiple boosted payments.

Federal officials are making it easier for homebound individuals to receive the COVID-19 vaccination – again.

The Centers for Medicare & Medicaid Services (CMS) this week announced that healthcare providers will now be eligible to receive additional enhanced payments for administering vaccines to multiple residents in one home setting or a communal setting of a home – up to five such payments, when fewer than 10 Medicare beneficiaries get the vaccine on the same day in the same setting.

“We are doing everything we can to remove barriers to vaccinations, including ensuring appropriate payment levels for vaccine providers to connect with more people in their communities who are unable to receive the vaccine in a traditional setting,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “We’ve seen the difference that vaccinations have in communities, and we are calling on providers to join us as we continue to increase vaccination rates across the country. Today’s actions ensure that everyone has the ability to be vaccinated against COVID-19, including older adults with mobility or transportation challenges and other at-risk individuals.”

While many Medicare beneficiaries are able to receive a COVID-19 vaccine at a retail pharmacy or from a healthcare provider, CMS noted, some have difficulty leaving their homes or cannot easily access a vaccination in such settings.

“These individuals are often at-risk patients who could require complex care if they contracted COVID-19 and needed to be hospitalized,” CMS said in a press release. “To better serve this group, Medicare previously increased the total payment amount for at-home vaccination from approximately $40 to approximately $75 per vaccine dose, in certain circumstances.”

Delivering vaccinations to homebound individuals poses certain unique challenges, officials acknowledged – such as ensuring appropriate vaccine storage temperatures, handling, and administration.

The additional payment amount also accounts for the clinical time needed to monitor a beneficiary after the vaccine is administered, as well as upfront costs associated with administering the vaccine safely and appropriately in a beneficiary’s home. The payment rate for administering each dose of a COVID-19 vaccine, as well as the additional in-home payment amount, is geographically adjusted based on where the service is furnished.

The nationwide campaign to vaccinate as much of the U.S. population as possible has achieved staggering results, although plenty more work remains: in far less than a year, 201.7 million people (71 percent of Americans age 12 and older) have received at least one dose, according to the New York Times. If the current pace holds, 90 percent of those 12 and older will be vaccinated by the end of March 2022, pushing herd immunity out of the realm of the merely hypothetical. 

Yet vaccination rates continue to vary wildly from state to state, with higher rates on both coasts and lagging rates in the Midwest and Southeast. The share of state populations that have received at least one COVID-19 vaccination reportedly range from a low of 43 percent in Idaho to a high of 76 percent in Vermont.

There has also recently been a dramatic surge in new cases, largely driven by the delta variant of the virus: the Centers for Disease Control and Prevention (CDC) just reported a seven-day moving average of 133,000 cases over the last week – up 14 percent compared to the week before, and up 95 percent from last summer’s peak of 69,000 cases. Still, the recent figure is down dramatically from the pandemic’s worst peak of about 254,000 cases a week, recorded in January 2021. 

The federal government continues to provide the COVID-19 vaccine free of charge or with no cost-sharing for Medicare beneficiaries, and as a condition of receiving free COVID-19 vaccines from the federal government, providers cannot charge patients any amount for administration. But they’re not the only ones for whom the service comes free of charge:

  • State Medicaid and the Children’s Health Insurance Program (CHIP) agencies must cover COVID-19 vaccine administration with no cost sharing for nearly all beneficiaries throughout the COVID-19 public health emergency (PHE) and generally for over a year after it ends. For the very limited number of Medicaid beneficiaries who are not eligible for this coverage (and do not receive it through other coverage they might have), providers may submit claims for reimbursement for administering the COVID-19 vaccine to underinsured individuals through the COVID-19 Coverage Assistance Fund, administered by the Health Resources and Services Administration (HRSA).
  • Under the American Rescue Plan Act of 2021 (ARP), the federal matching percentage for state Medicaid and CHIP expenditures on COVID-19 vaccine administration is currently 100 percent (as of April 1, 2021), and will remain as such for more than a year after the PHE ends. The ARP also expands coverage of COVID-19 vaccine administration under Medicaid and CHIP to additional eligibility groups. CMS recently updated the Medicaid vaccine toolkit to reflect the enactment of the ARP at https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf.
  • The vaccine is also free for people enrolled in most private health plans. The COVID-19 vaccines and the administration are covered without cost sharing for most enrollees, and such coverage must be provided both in-network and out-of-network during the PHE. Current regulations provide that out-of-network rates must be reasonable as compared to prevailing market rates, and the rules reference using the Medicare payment rates as a potential guideline for insurance companies.

“In light of CMS’s action today, CMS expects health insurance issuers and group health plans to continue to ensure their rates are reasonable when compared to prevailing market rates,” the agency’s press release read. “Under the conditions of participation in the CDC COVID-19 Vaccination Program, providers cannot charge plan enrollees any administration fee or cost sharing, regardless of whether the COVID-19 vaccine is administered in-network or out-of-network.”

More information on Medicare payment for COVID-19 vaccine administration – including a list of billing codes, payment allowances and effective dates – is available at https://www.cms.gov/medicare/covid-19/medicare-covid-19-vaccine-shot-payment.

More information regarding the CDC COVID-19 Vaccination Program Provider Requirements and how the COVID-19 vaccine is provided through that program at no cost to recipients is available at https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html.

CMS also continues to encourage unvaccinated individuals and those looking to assist friends and family to take the following steps:

  1. Visit vaccines.gov (English) or vacunas.gov (Spanish) to search for vaccines nearby;
  2. Text GETVAX (438829) for English or VACUNA (822862) for Spanish for near-instant access to details on three vaccine sites in the local area; and
  3. Call the National COVID-19 Vaccination Assistance Hotline at 1-800-232-0233 (TTY: 1-888-720-7489) for assistance in English and Spanish.

The COVID-19 pandemic has reportedly sickened nearly 215 million people and killed 4.46 million worldwide. The U.S. continues to lead the world in both categories, with more than 38 million cases and nearly 650,000 deaths.

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