Medicare and most private insurers will cover COVID-19 vaccines approved by the Food and Drug Administration at no cost to beneficiaries, CMS said Wednesday.
CMS will pay for any coronavirus vaccine that receives standard approval, an Emergency Use Authorization or is licensed under a Biologics License Application. The interim final rule also implements parts of the CARES Act "to ensure swift coverage of a COVID-19 vaccine by most private health insurance plans without cost-sharing from both in and out-of-network providers during the course of the public health emergency," CMS said in a statement.
Medicaid and Children's Health Insurance Program beneficiaries can also receive cost-free vaccines. The Provider Relief Fund will pay vaccine administration costs for the uninsured.
"Providers who receive free COVID-19 vaccines from the federal government will be prohibited from charging consumers any additional cost for the administration of the vaccine beyond what their insurance covers. Surprise or balance billing for vaccine costs is strictly prohibited," CMS Administrator Seema Verma said during a press call.
CMS will pay $28 to administer a single dose vaccine. For a COVID-19 vaccine requiring two or more doses, the agency will pay $17 for the first dose and $28 for the last dose, according to a CMS fact sheet. The agency hopes private payers and state Medicaid plans will follow Medicare's lead. According to Verma, it would cost Medicare about $2.6 billion if all seniors get immunized.
The agency created toolkits for providers, insurers and states to inform them about vaccine coverage and administration, Medicare reimbursement and how providers can enroll in Medicare to administer the vaccine. CMS hopes to enroll new Medicare providers, including pharmacies and other non-traditional providers, to expand access to COVID-19 vaccination.
"As Operation Warp Speed nears its goal of delivering the vaccine in record time, CMS is acting now to remove bureaucratic barriers while ensuring that states, providers and health plans have the information and direction they need to ensure broad vaccine access and coverage for all Americans," CMS Administrator Seema Verma said in a statement.
The rule allows hospitals to qualify for additional outlier payments when they treat patients with new products approved or authorized to treat COVID-19 to reduce any losses they may experience from making the therapies available, even if they don't reach the current outlier threshold of $30,000. Medicare will pay an extra 65% of the cost for new COVID therapies in an inpatient hospital setting. It's similar to CMS' add-on payments for new technologies. The program will also pay separately for outpatient services for COVID-19 treatments.
"New COVID-19 therapeutics will automatically qualify for the additional payment during the public health emergency after they've been approved by the FDA," Verma said. "This will eliminate financial disincentives that hospitals may face for furnishing potentially life-saving treatments."
Providers will bill traditional Medicare instead of Medicare Advantage plans for COVID-19 vaccinations administered to MA beneficiaries. The fee-for-service program will pay to vaccinate all Medicare and MA enrollees.
"We are working closely with the American Medical Association to release specific billing codes for each vaccine," Verma said.
CMS mandated that providers post their prices for COVID-19 diagnostic testing online. If a provider doesn't have a website, they have to make those prices available in writing and on signage. The agency could fine providers up to $300 per day if they don't post their prices.
The rule also extended the Comprehensive Care for Joint Replacement model's fifth performance year by six months. It will now end Sept. 30.
CMS can now change the public participation requirements for state innovation waivers submitted during the public health emergency to fast-track waiver requests.
