COVID-19 vaccines are available at no cost to anyone living in the United States. However, professionals may charge a vaccine administration service fee to insurance providers.
To take into account evolving vaccination strategies, the Centers for Medicare & Medicaid Services (CMS) recently announced updates and changes to these fees. The information below is provided to assist you in filing for reimbursement and clearly explaining the vaccine administration fee process to vaccine recipients.
As Ohio strives to make vaccines accessible to all populations, many approaches that involve meeting people in their communities and reaching the homebound have become increasingly important. CMS has increased the Medicare reimbursement rate to providers vaccinating a recipient in the recipient’s home by $35 (for a total of approximately $75) per dose. For a two-dose vaccine, this results in a total payment of approximately $150 for administering both doses.
The Ohio Department of Medicaid (ODM) is matching the Medicare rate for vaccinations provided to recipients in their homes. The increase covers the upfront costs associated with administering the vaccine safely and appropriately in someone’s home, as well as the clinical time needed to monitor a recipient after the vaccine is administered. This payment rate will be adjusted based on geographic location.
CMS has a variety of information available for providers on its website, as well as a toolkit.
- Original Medicare and Medicare Advantage: Medicare beneficiaries pay nothing for COVID-19 vaccines or administration, and there is no applicable copayment, coinsurance, or deductible.
- Medicaid and the Children’s Health Insurance Program (CHIP): State Medicaid and CHIP agencies must cover COVID-19 vaccine administration with no cost-sharing for nearly all beneficiaries during the federal COVID-19 public health emergency (PHE) and for one year after it ends.
- ODM’s COVID-19 Vaccine Administration Billing Guidelines can be found on ODM’s website.
- Generally, the Medicaid Managed Care Plans (MCPs) follow the fee-for-service Medicaid billing guidelines. Professionals are encouraged to contact the MCPs directly regarding claim submission questions.
- From June 10, 2021, through August 15, 2021, all Medicaid MCPs are increasing professional reimbursement rates to $100 for administering COVID-19 vaccines to Medicaid patients. MCPs are also providing $50 gift cards to Medicaid members ages 18-years and older who receive at least one dose of COVID-19 vaccine (first dose of the Pfizer or Moderna vaccine or the single-dose Johnson & Johnson vaccine). Vaccine providers can partner with the MCPs to market vaccination opportunities and distribute member incentives at the point of vaccination. These time-limited vaccination efforts are part of the MCPs’ response to Governor Mike DeWine’s challenge to raise the Medicaid vaccination rate to match the statewide rate by August 15. Please contact the MCPs directly to learn more about these time-limited enhanced reimbursement and incentive opportunities.
- For a minimal number of Medicaid beneficiaries who are not eligible for this coverage: Professionals may submit claims for reimbursement for administering the COVID-19 vaccine to underinsured individuals. This is available through the COVID-19 Coverage Assistance Fund, administered by the Health Resources and Services Administration (HRSA).
- For uninsured individuals: Providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the HRSA. Visit the HRSA website for information on the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured program.
- Under the American Rescue Plan Act of 2021 (ARP), signed by President Biden on March 11, 2021, the federal matching percentage for state Medicaid and CHIP expenditures on COVID-19 vaccine administration is 100% (as of April 1, 2021) and will remain 100% for more than a year after the COVID-19 PHE ends. The ARP also expands Medicaid and CHIP coverage of COVID-19 vaccine administration to additional eligibility groups.
- The vaccine is free for people enrolled in private health insurance plans: The COVID-19 vaccine and its 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 compared with prevailing market rates, and rules suggest insurance companies use Medicare payment rates as a potential guideline.
- 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 compared with prevailing market rates. 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.
If you have any questions or issues, please call the Ohio Department of Health Call Center between 8 a.m. and 7 p.m., Monday through Friday, at 1.844.963.4829 or email COVIDVACCINE@odh.ohio.gov.