CMS nearly doubles the payment rate for administering the COVID-19 vaccine in a Medicare beneficiary’s home

The payment increase is part of a strategy to improve vaccination rates, which have slowed in recent weeks.

Seeking to boost COVID-19 vaccination rates, CMS has increased the payment rate to healthcare providers that administer the vaccine in the homes of Medicare beneficiaries who have trouble traveling to receive their shots.

Medicare has bumped the payment rate from $40 to approximately $75 per dose for those beneficiaries, meaning a two-dose regimen would pay about $150. CMS notes that the rate is subject to geographical adjustment.

President Joe Biden set a goal of at least partially vaccinating 70% of Americans by July 4, but to meet that mark about 15 million more people would need to receive a dose. That could be a stretch with daily vaccinations dropping below 500,000, down from 2 million a day in April, according to news reports.

The higher payment rate is intended to cover the logistical challenges of vaccinating homebound beneficiaries, along with up-front costs and the clinical time needed to monitor a beneficiary after the vaccine is administered, CMS stated in a news release.

CMS has provided this list of vaccine administration codes that apply during the public health emergency.

Criteria for in-home vaccination eligibility

Providers can receive the higher payment rate for an in-home vaccination if a Medicare beneficiary:

• Has difficulty leaving home due to illness, injury or disability, including any condition that makes the beneficiary more vulnerable to contracting disease
• Is considered “hard to reach” due to socioeconomic or geographical barriers

Locations that qualify for the in-home payment rate include:

• Private residences
• Temporary lodging such as hotel rooms
• Homes that are “made provider-based to a hospital during the COVID-19 public health emergency”

Hospitals and nursing facilities — even those that are the beneficiary’s permanent residence — don’t qualify for the additional payment rate, nor do communal spaces within a multiunit living arrangement.

Providers won’t receive the higher payment rate for administering the COVID-19 vaccine in a Medicare beneficiary’s home if other Medicare services are being provided in the location on the same date.

The $35 payment bump is available for a vaccine administered to only one beneficiary per home on a given date. If a second beneficiary in the same home receives the vaccine on the same date, the payment for that dose would be the standard rate.

Effect on commercial payment rates

Commercial health plans must offer out-of-network vaccination coverage during the COVID-19 public health emergency, according to federal rules.

“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,” CMS wrote. “In light of CMS’s increased Medicare payment rates, CMS will expect health insurance issuers and group health plans to continue to ensure their rates are reasonable when compared to prevailing market rates.”

Additional options for reimbursement

Providers cannot charge vaccine recipients an administration fee or cost-sharing amount, regardless of whether the recipient is in-network. Two programs operated by the Health Resources and Services Administration are intended to reimburse providers if a vaccine recipient is underinsured or uninsured.

Those programs are:

The Coverage Assistance Fund for recipients whose health plans either don’t cover the vaccine or require cost sharing

The COVID-19 Uninsured Program, part of the Provider Relief Fund