Insights

COVID-19: Vaccine and Treatment Billing Guide Under Medicare


  • Pfizer-BioNTech COVID-19 Vaccine
  • Moderna COVID-19 Vaccine
  • AstraZeneca COVID-19 Vaccine
  • Bamlanivimab EUA
  • Regeneron (Casirivimab + Imdevimab) EUA

Update Overview - December 28th, 2020

Over the last several weeks, the Federal Drug Administration (FDA) has approved, or is in the process of approving, Emergency Use Authorization (EUA) to Pfizer, Moderna, Eli Lilly and Regeneron Pharmaceuticals for their COVID-19 Vaccines or Infusion Treatment. The United States government, through Operation Warp Speed, has been working since the onset of the pandemic to make one or more COVID-19 vaccines and infusions available as soon as possible.

Additional information can be found in the COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations published by the Centers for Disease Control and Prevention (CDC) in October here: https://www.cdc.gov/ vaccines/imz-managers/downloads/COVID-19-Vaccination-Program-Interim_Playbook.pdf

Initially, a limited supply of COVID-19 vaccines have been distributed to healthcare organizations. Vaccination efforts will focus on those critical to the response. Those include first responders and frontline healthcare workers providing direct care, as well as those at the highest risk for developing severe illness from COVID-19. 

Examples:

  • Phase 1a Distribution:
    • Healthcare personnel (paid and unpaid persons serving in healthcare setting who have the potential for direct or indirect exposure to patients or infections materials)
    • Residents living in Long Term Care Facilities
  • Phase 1b Distribution:
    • Non-healthcare essential workers (Law Enforcement, EMT/Paramedic)
    • Adults 75 years and older 
  • Phase 1c Distribution:
    • Adults with high-risk medical conditions who possess risk factors for severe COVID-19 illness
    • Other essential workers
To review the CDC published recommendation on vaccine distribution, click HERE. CMS has published Vaccination Provider Guidance to include a toolkit, enrollment and billing information, and more. Click HERE to review.

Enrollment

Payment for Product

  • During the COVID-19 public health emergency (PHE), Medicare will cover and pay for these infusions the same way it covers and pays for COVID-19 vaccines (when furnished consistent with the EUA). This in accordance with Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).
  • The vaccine itself will be paid for through funding authorized by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, but administration of the vaccine by a provider will be paid for by the payer (for example, the private insurance company, Medicare in the case of a Medicare Advantage plan, or the Provider Relief Fund). Consumers enrolled in non-grandfathered group or individual health insurance coverage will be able to receive the vaccine and its administration free of charge from a network provider, and during the COVID-19 PHE, will also be able to receive the vaccine and its administration free of charge from an out-of-network provider. Providers are prohibited by agreement with the U.S. Government from billing patients for the vaccine or its administration, including balance billing.
  • Medicare will not provide payment for the monoclonal antibody products that health care providers receive for free, as will be the case for the product’s initial availability in response to the COVID-19 PHE.
  • IF, healthcare providers begin to purchase these monoclonal antibody products (after the initial offering), CMS anticipates setting payment rates the same as it does for COVID-19 vaccines. For example, Medicare will pay 95% of the average wholesale price (AWP) for COVID-19 vaccines provided/furnished in physician office settings and pay hospital outpatient departments at reasonable cost for COVID-19 vaccines.
  • Medicare Beneficiaries pay no cost sharing for these monoclonal antibody infusion:
    • No co-payment/coinsurance
    • No deductible

Payment for Vaccines/Infusions

  • Initial payment rate for Pfizer and Moderna vaccines is inclusive of the vaccine and administration (separate CPT/HCPC codes for the vaccine and administrations)
  • Initial payment rate for Eli Lilly and Regeneron infusions are inclusive of the preparation time, one (1) hour infusion time and post-administration monitoring while in the hospital OP setting (Single HCPC codes for the drug as well as the infusion)
  • Initial payment rate for Eli Lilly and Regeneron vaccines are inclusive of the vaccine and administration (Single HCPC codes for the drug as well as the administration)
  • Rates will be geographically adjusted, see charging table for additional detail

Registration Guidelines

  • Accounts should be registered as OP status
  • Some clients HIS systems may have identified unique patient types for each vaccine dose 
  • Insurance plans for insured patients should be appropriately added based on current insurance verification processes 
  • There will be no upfront collections of POS for these encounters

*Note: Registration guidelines may change based on the phase of distribution.

Uninsured and Self-Pay Guidelines

  • HRSA (Health Resource & Service Administration)/COVID insurance plan as identified by each provider should be added in the instances where a patient does not have insurance 
  • Providers administering vaccine to patients without insurance can request reimbursement through the Provider Relief Fund. Click HERE for further details on uninsured claims.

These materials are for general informational purposes only. These materials do not, and are not intended to, constitute legal or compliance advice, and you should not act or refrain from acting based on any information provided in these materials. Please consult with your own legal counsel or compliance professional regards specific legal or compliance questions you have.

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