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  • Washington Highlights

    CMS Releases Rule on Coverage and Payment for COVID-19 Vaccines and Therapeutics


    Gayle Lee, Director, Physician Payment & Quality

    The Centers for Medicare & Medicaid Services (CMS) issued a fourth Interim Final Rule, effective immediately, that addresses the COVID-19 public health emergency (PHE). The new rule includes provisions related to vaccine payment and coverage, price transparency for COVID-19 tests, payment for COVID-19 therapeutics, Medicaid enrollment, and the comprehensive joint replacement model.

    The rule, released Oct. 28, states that Medicare will cover the cost of COVID-19 vaccines and their administration and that it will waive out-of-pocket costs for beneficiaries in Fee-for-Service and Medicare Advantage.

    The rule also requires Medicaid, Children’s Health Insurance Program agencies, and most private health plans to administer the vaccine at no cost to patients during the public health emergency (PHE). The Department of Health and Human Services will cover the vaccine and its administration for any uninsured individual through the CARES Act provider relief fund. The CMS is working collaboratively with the American Medical Association to develop specific vaccine codes that would be used for billing and tracking the different vaccines.

    The rule includes the following additional provisions:

    • Physicians and other health care professionals who perform COVID-19 diagnostic tests must post their cash prices on their website.
    • The CMS will pay hospitals add-on payments in the inpatient and outpatient settings for COVID-19 therapeutics.
    • The CMS creates flexibilities for states maintaining Medicaid enrollment during the COVID-19 PHE.
    • The CMS extends the Comprehensive Care for Joint Replacement Model for six months. It now ends on Sept. 30, 2021.

    The CMS also released a fact sheet, COVID-19 vaccine resources, and FAQs on billing for therapeutics.