In the US COVID vaccines are 100% free to all individuals. Only insurance companies or the federal government can be billed for medical reimbursement, not patients. For COVID vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies, and other immunizers will be $40 per dose. If you look closely the covid vaccine reimbursement for single-dose vaccines costs nearly $28 to $40 for a single and $45 to $80 for two doses.
However, the exact payment is mainly depending on two factors like the type of entity that furnishes the service and geographical location based on where the service is furnished.
Proper medical billing for the Covid vaccine is important to get reimbursement. Moreover, each Covid vaccine has its own specific CPT code based on the vaccine manufacturer (Pfizer or Moderna) like Vaccine CPT: 91300, Administration: 0001A, ICD-10: Z23, NDC: 59267-1000-01 for Pfizer, and Vaccine CPT: 91301, Administration: 0011A ICD-10: Z23, NDC: 80777-0273-10 for Moderna.
When it comes to the vaccine administration code, you need to know that these codes are based on two factors like the manufacturer and the number of doses.
CMS is working hard to ensure that all Americans are vaccinated against COVID-19 at the earliest by supporting provider efforts to expand capacity. Moreover, the agency is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with new Medicare payment rates. CMS makes it mandatory that no beneficiary, whether covered by private insurance, Medicare, or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.
As we have already seen, every citizen in the US is offered free COVID-19 vaccines from the federal government, hence vaccine providers are prohibited from charging patients any amount for administration of the vaccine. Let’s understand coverage of COVID-19 vaccines to justify the government efforts.
Coverage for COVID vaccine reimbursement
No beneficiaries are liable to pay for COVID-19 and there is no applicable copayment, coinsurance, or deductible. If you have Medicare and have a disability or face other challenges in getting to a location away from home for a vaccination, Medicare will pay a doctor or other care provider to give you the COVID-19 vaccine in your home. You may need to give them your Medicare Number for billing, but there’s still no cost to you for the covid vaccine and its administration.
Medicare Advantage (MA):
As mentioned above Medicare will offer covid vaccine reimbursement to providers directly (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines like Medicare beneficiaries.
CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost-sharing during the public health emergency (PHE). Based on the current regulations rate for out-of-network service must be reasonable compared with prevailing market rates though CMS’s increased Medicare payment rates.
State Medicaid and CHIP agencies must provide vaccine administration with no cost-sharing for nearly all beneficiaries during the public health emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID-19 vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage.
For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).