Under a plan announced on Oct. 28, Wednesday, Medicare will cover the cost of administering the vaccine for seniors. In addition, regulatory changes will apply to Medicaid beneficiaries.
The plan is part of a reimbursement strategy that will also cover testing for the coronavirus.
The new rules go into effect immediately, though there is a 30-day comment period. Further adjustments to it could be made after comments are received.
Back in March, Congress passed the CARES Act, which made the administration of any COVID-19 vaccine free. That said, there was one hitch: Medicare does not cover drugs and vaccines that get emergency-use authorization. This is because the authorization for these drugs has lower standards than the criteria used in typical drug approvals.
The new rule from the Centers for Medicare & Medicaid Services (CMS) is meant to overcome that hurdle. According to administration officials, this means that they won’t have to go to Congress to seek a fix.
Under the new rule, Medicare, which covers about 62.7 million Americans, will cover the cost of administering the vaccines given emergency-approval by the Food and Drug Administration (FDA) and given in an out-patient setting.
The Trump administration currently has agreements with the companies racing to produce a COVID-19 vaccine – AstraZeneca (alongside the University of Oxford), Moderna and Pfizer – to produce 100 million vaccine doses as soon as the end of the year. All three are currently well into phase three clinical trials for their vaccines, and Pfizer is hoping to apply for emergency-use authorization next month. (Related: Myelitis observed in two COVID-19 vaccine trial participants is a common vaccine injury.)
“Now we’re seeing this greater effort on how we are going to get every American vaccinated,” said CMS Administrator Seema Verma. “We’re coordinating across the entire health care delivery system, private and public.”
In addition to those under Medicare, the rule also comes with a provision to ensure that people with private health care plans also get free coronavirus vaccines during the pandemic. Free vaccines were actually stipulated in the Cares Act, whether they are in or out of network.
The federal government will shoulder the cost of the vaccines.
“It’s a free vaccine, they can’t balance bill,” explained Verma. Balance billing happens when doctors have to bill patients for the difference between their actual charges and the amount covered by insurance.
Doctors, nurses and other provides will be reimbursed around $17 for administering the first dose of the vaccine and $28 for the second. The amount increase for the second dose is partly due to the fact that providers may have to do more outreach to get people to come in twice.
The new rule announced Wednesday covers COVID-19 vaccines. With it, all providers of COVID-19 tests, as well as facilities that conduct testing, will also have to post the cash price of the tests.
The requirements come following mounting concern from some lawmakers and health-care advocates about the out-of-pocket costs that some people are paying for coronavirus tests. Currently, the price of COVID-19 testing can vary widely. According to a study from the Kaiser Family Foundation, large hospitals around the country charge from $20 to over $800 for a single out-of-network test.
Under the new rule, providers of COVID-19 tests who fail to post their cash prices for tests online could face fines of up to $300 a day. The fines are meant to ensure that there is price disclosure around any possible out-of-pocket costs for tests. Insurers will also use the cash price to determine how much to reimburse.
The new rule that adds increased reimbursement for COVID-19 testing and vaccination is a departure for the CMS. It aims to speed up access to COVID-19 testing and, more importantly, vaccination from the drug makers vying for FDA approval.
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