Jeffrey Wade
The COVID-19 pandemic has brought the topic of reimbursements for vaccines, and the role of commercial insurance carriers, into sharp focus. The Biden-Harris Administration has increased the Medicare payment amount for administering the COVID-19 vaccine, with the aim of supporting providers in their efforts to expand capacity and vaccinate more people each day. This has also resulted in greater reimbursement for vaccine providers. The CMS, along with the Departments of Labor and Treasury, has required that most private health plans and issuers cover the COVID-19 vaccine and its administration, with no cost-sharing. This has also been reflected in the HPV vaccination, with studies showing that insurance reimbursements for HPV vaccination in the private sector have increased over time.
| Characteristics | Values |
|---|---|
| COVID-19 vaccine administration | Covered by most private health plans and issuers, with no cost sharing |
| Out-of-network rates | Must be reasonable and comparable to prevailing market rates |
| Uninsured individuals | Providers may submit claims for reimbursement for administering the COVID-19 vaccine through the Provider Relief Fund |
| Medicare Part B | Covers the administration of influenza, pneumococcal polysaccharide and booster for high-risk persons, and hepatitis B vaccines |
| HPV vaccine | Mean reimbursement of $159.17 for the vaccine and $23.91 for administration between 2007 and 2014 |
| HPV vaccine | 3-dose quadrivalent HPV vaccine series cost $423 in the private sector in 2014 |
| HPV vaccine | Medicaid-enrolled children receive HPV vaccines at no cost |
| HPV vaccine | Private providers are responsible for purchasing vaccines and other costs such as storage and insurance |
| Group purchasing | Can lower the per-unit costs of vaccines and supplies |
| Free or discounted vaccines | Vaccines for Children (VFC) program provides free vaccines for eligible persons from birth through 18 years |
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What You'll Learn
COVID-19 vaccine reimbursements
The COVID-19 vaccine is provided free of charge by the federal government to all people living in the United States. However, pharmacies and healthcare providers are facing challenges in getting reimbursed for the vaccines they administer.
The Health Resources and Services Administration (HRSA) has established two programs to provide claims reimbursement for COVID-19 vaccines: the HRSA COVID-19 Uninsured Program and the HRSA COVID-19 Coverage Assistance Fund. The HRSA COVID-19 Uninsured Program provides reimbursement to healthcare providers for COVID-19 testing, treatment, or vaccine administration for uninsured individuals. The HRSA COVID-19 Coverage Assistance Fund, on the other hand, reimburses providers for COVID-19 vaccine administration provided to individuals who have health insurance but are underinsured in terms of COVID-19 vaccination coverage. This includes individuals whose health plans do not cover COVID-19 vaccination or require cost-sharing.
To facilitate the claims process and minimize the risk of rejection, resources such as guides and videos have been developed. For instance, the National Community Pharmacists Association (NCPA) has created a 3-page "Vaccine Billing and Reimbursement" guide and a 20-minute video presentation, "Troubleshooting COVID-19 Vaccine Billing Issues," to offer guidance to pharmacists on seeking reimbursement under different programs, including commercial plans.
In New York, Attorney General Letitia James has also taken action to secure reimbursements for consumers who were wrongfully charged administration fees by pharmacies for their COVID-19 vaccine. These pharmacies have reimbursed affected individuals and have implemented stronger training programs to prevent such incidents from recurring.
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HPV vaccine reimbursements
In the United States, the Centers for Disease Control and Prevention (CDC) vaccine list price is used as a benchmark by the private sector for HPV vaccine cost reimbursement. However, reimbursement for vaccine costs varies. For instance, in 2017-2018, the CDC-recommended pricing per HPV vaccine dose for the private sector was $210.99. However, the recommended vaccine purchase reimbursement and immunization incentive by the AAP is 125% ($263.74) of the CDC vaccine price list for the private sector.
The specialty of the clinician (pediatrician, family physician, internal medicine specialist, nurse practitioner, etc.) who administered the HPV vaccine is also considered in reimbursement calculations. In 2017-2018, the average reimbursements for HPV vaccine purchase costs were estimated for these five specialties and compared using statistical tests. Net returns from HPV vaccine cost reimbursements are lowest for family physicians ($0.34/dose) and highest for pediatricians ($5.08/dose).
A study examining insurance reimbursements and trends for HPV vaccine purchase and administration reimbursement from 2007 to 2014 found that the mean vaccine purchase reimbursement was $159.17, while the mean vaccine administration reimbursement was $23.91. During this period, vaccine purchase reimbursements remained relatively stable, but vaccine administration reimbursements increased.
It is worth noting that insurance reimbursement rates for HPV vaccines can vary significantly across different states and geographic locations. This variation may be influenced by factors such as population health, healthcare utilization patterns, and competition among insurance carriers within a state.
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Higher payments to support vaccination efforts
The Biden-Harris Administration has increased the Medicare payment amount for administering the COVID-19 vaccine. This higher payment rate will support actions taken by providers to increase the number of vaccines they can furnish each day. This includes establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff. The payment boost is also designed to increase the number of providers that can administer the vaccine.
Effective from March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies, and many other immunizers will be $40 to administer each dose of a COVID-19 vaccine. This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines and an increase from $45 to $80 for two-dose vaccines. The payment rate may vary based on the type of entity that administers the vaccine and is subject to geographical adjustments.
The American Rescue Plan Act, signed by President Biden on March 11, ensures that the COVID vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. CMS, along with the Departments of Labor and Treasury, requires 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.
In the case of uninsured individuals, providers may submit claims for reimbursement for administering the COVID-19 vaccine through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).
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Commercial insurance carriers and vaccine coverage
Commercial insurance carriers play a crucial role in ensuring vaccine coverage and accessibility for their members. While specific reimbursement policies may vary across different carriers, there are some common trends and regulations that influence vaccine coverage.
One notable aspect is the reimbursement rates for vaccine administration. During the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) increased the reimbursement rates for administering the COVID-19 vaccine. This was done to support healthcare providers in expanding their vaccination efforts and ensuring swift vaccine distribution. Commercial insurance carriers were expected to follow suit and maintain reasonable rates compared to prevailing market rates.
Prior to the COVID-19 pandemic, CMS had also issued reimbursement rates for other vaccines, such as the human papillomavirus (HPV) vaccine. Studies examining insurance reimbursements for HPV vaccination in the private sector found that the mean vaccine purchase reimbursement was $159.17, while the mean vaccine administration reimbursement was $23.91. These rates can vary depending on the specific vaccine and the costs involved in its administration.
It is important for healthcare providers to communicate with insurance carriers to verify vaccine coverage and administration policies. Reimbursement rates can differ between carriers, and proper coding is essential to ensure timely and accurate reimbursement. Additionally, federal regulations, such as the Affordable Care Act (ACA), mandate certain vaccines to be provided without cost-sharing for eligible individuals.
Furthermore, commercial insurance carriers should also consider the availability of free or discounted vaccines through federal programs. For example, the Vaccines for Children (VFC) program offers free vaccines for eligible individuals from birth through 18 years of age. By utilizing such programs, healthcare providers can reduce initial and overhead costs associated with vaccine procurement.
In summary, commercial insurance carriers play a vital role in vaccine coverage by providing reimbursement for vaccine purchase and administration. They are expected to maintain reasonable rates and ensure accessibility for their members. Healthcare providers should stay informed about reimbursement policies, communicate with carriers, and explore opportunities for cost reduction to enhance vaccine coverage and accessibility.
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Medicare and Medicaid vaccine reimbursements
Medicare and Medicaid beneficiaries do not have to pay for the COVID-19 vaccine, and there is no applicable copayment, coinsurance, or deductible. Medicare covers the costs of the COVID-19 vaccine and its administration, with providers receiving an increase in the Medicare payment rate for administering the vaccine. This payment boost aims to support providers in increasing the number of vaccines they can furnish each day, including expanding vaccination sites, conducting patient outreach and education, and hiring additional staff.
The Centers for Medicare and Medicaid Services (CMS) have updated their toolkits to ensure adequate payment for administering the COVID-19 vaccine to Medicare beneficiaries. The national average payment rate for physicians, hospitals, pharmacies, and other immunizers is $40 per dose administered, an increase from approximately $28 for single-dose vaccines. For two-dose vaccines, the increase is from $45 to $80. However, the payment rate may vary based on the type of entity administering the vaccine and is subject to geographical adjustments.
In the context of routine adult vaccinations, such as the influenza vaccine, Medicare also waives the patient copay. The Medicare national average rate of reimbursement for certain CPT codes related to vaccine administration is $16.94, while for other CPT codes, it is $12.97. Medicare beneficiaries must use their new Medicare cards, which do not display their Social Security number, when seeking reimbursement for vaccine-related services.
Regarding Medicaid, there have been concerns about adequate reimbursement for Federally Qualified Health Centers (FQHCs) administering the COVID-19 vaccine. In some states, vaccine-only visits do not trigger a Medicaid billable visit for FQHCs, resulting in low or no additional administration fees. Efforts are being made to address this issue and ensure FQHCs receive appropriate reimbursement for their critical role in vaccinating vulnerable communities.
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Frequently asked questions
Effective March 15, 2021, the national average payment rate for administering each dose of the COVID-19 vaccine is $40. This is an increase from the previous rate of $28 for single-dose vaccines and $45 for two-dose vaccines.
No, beneficiaries with private insurance, Medicare or Medicaid do not need to pay for the COVID-19 vaccine. There is no applicable copayment, coinsurance or deductible.
Yes, providers serving privately insured children are responsible for purchasing HPV vaccines as well as other vaccination-related costs such as storage costs, personnel costs, insurance payment against loss of the vaccine, and recovery of costs attributable to inventory shrinkage.
One strategy is to join the Vaccines for Children (VFC) program, a federal program that provides free vaccines for eligible persons from birth through 18 years of age. Another strategy is to join with other providers for bulk or group purchasing, which can lower the per-unit costs of vaccines.
