CMS issues coverage rules for COVID-19 vaccine: 10 things to know

Medicare, Medicaid and private insurers will all be required to cover a COVID-19 vaccine without any out-of-pocket costs for beneficiaries and members, CMS said Oct. 28.

Ten things to know: 

1. Under an interim final rule, providers won't be allowed to charge consumers for administering a vaccine.

Medicare

2. Any FDA-authorized COVID-19 vaccine, including one approved through emergency use authorization, will be covered at no cost under Medicare. The Medicare rate is $28.39 for a single-dose vaccine. A vaccine with two or more doses will be reimbursed at $16.94 for initial doses and $28.39 for the final.

3. Medicare will pay directly for COVID-19 vaccines for members of Medicare Advantage plans from 2020-21. Beneficiaries' copayment and deductible will be waived.

Medicaid

4. CMS will require state Medicaid and Children's Health Insurance Program agencies to administer the vaccine at no cost for most members during the public health emergency, though it allows some flexibilities on that rule once the PHE period expires. 

Private insurance 

5. The Departments of Labor, Treasury and CMS are requiring most private health plans to cover a COVID-19 vaccine with no cost sharing, regardless of network status with a provider. The rule also states out-of-network rates can't be unreasonably low, pointing to Medicare reimbursement rates as a guidepost.

Uninsured

6. Americans without insurance will have access to free COVID-19 vaccines. Providers will be reimbursed through a Provider Relief Fund administered by the Health Resources and Services Administration. 

Hospital payments, prices

7. In addition to vaccine coverage, the interim final rule would provide additional payments to hospitals that use newly approved treatments on COVID-19 patients. The additional payments aim to mitigate potential losses from using the new therapies. CMS also provided information to hospitals on how to bill for outpatient administration of a monoclonal antibody treatment if one is ever approved by an emergency use authorization.

8. The interim final rule requires providers who perform a COVID-19 diagnostic test to post their cash prices online, or face fines.

Additional flexibilities 

9. In the interim final rule, CMS provides an extension of the fifth performance year of the Comprehensive Care for Joint Replacement model and provides more flexibility for states submitting section 1332 waivers.

10. The interim final rule has a 30-day comment period. 

View the full rule here.

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