Payment Information for COVID Vaccines

Current Payment Methods

Insured and uninsured individuals in the United States will not have to worry about paying for the COVID-19 vaccine. The Coronavirus Aid, Relief, and Economic Security (CARES) Act that was enacted in March 2020 discusses vaccine coverage. This Guidance requires health insurance plans to cover ACIP-recommended COVID-19 vaccines without cost sharing.

As of November 2020, Medicare beneficiaries (of any Medicare plan) do not have to pay for the COVID-19 vaccine. Medicare Part B and private Medicare Advantage plans are required to cover the cost for vaccines and administration as long as the vaccine has been granted an emergency use authorization (EUA) by the FDA. (https://www.cms.gov/covidvax-provider)

Individuals covered by private health insurance plans, whether through their employer or purchased as an individual plan through the healthcare marketplace, will also be eligible for vaccine coverage through their plan. According to the CARES Act, individuals with private health insurance are guaranteed rapid and full coverage for COVID-19 vaccination and administration. Private insurers regulated by the Affordable Care Act (ACA) are required to cover the COVID-19 vaccine through the duration of the public health emergency at no cost to the patient. 

Under traditional Medicaid, beneficiaries will be covered to receive the COVID-19 vaccine with no cost-sharing throughout the entirety of the public health emergency. States are not required to cover vaccines for beneficiaries that have limited benefit packages. After the public health emergency is over, vaccine coverage will be at the discretion of each state’s Medicaid program. (https://www.medicaid.gov/sites/default/files/2020-12/covid-19-vaccine-toolkit-12172020.pdf)

For patients who are uninsured or underinsured, the federal government is covering the cost of vaccines and administration during this time. Vaccines should be offered at no cost to all patients. No patient can be denied a vaccine if they are unable to pay. Providers can request reimbursement for administration of vaccines through the provider relief fund: https://www.hrsa.gov/CovidUninsuredClaim 

(https://www.cdc.gov/coronavirus/2019-ncov/vaccines/keythingstoknow.html )

CARES Act: https://www.congress.gov/bill/116th-congress/house-bill/748/text

(https://www.verywellhealth.com/how-will-my-health-insurance-cover-a-covid-19-vaccine-5090168)

How to Bill

Whether a patient is covered by a federal or private insurance plan, there are specific billing procedures that must be followed to ensure proper reimbursement for the vaccine and administration services. 

Medicare: If the vaccine is being covered by the government, pharmacies only have to bill for administration. Under these circumstances, pharmacies should not include vaccine codes on the claims. Pharmacies can submit claims for patients individually on separate claims or they can submit claims on a roster bill for multiple patients at one time. (https://www.cms.gov/medicare/covid-19/medicare-billing-covid-19-vaccine-shot-administration)

Medicaid: NC Medicaid has released specific guidance on how pharmacies should bill for COVID-19 vaccines. The guidance specifies all relevant information for appropriate billing and reimbursement for administration. This information can be found at the following link from NCDHHS: https://medicaid.ncdhhs.gov/blog/2021/01/21/special-medicaid-bulletin-covid-19-152-billing-guidance-covid-19-vaccines

Private Insurers: For private insurance plans, pharmacies should first attempt to bill the patient’s prescription insurance coverage (if applicable). If prescription insurance does not work, pharmacies can then bill patients’ medical insurance plans. If pharmacies have trouble billing vaccines to private insurers, they should contact the patient’s individual plan or visit their website for more guidance.

Uninsured: Uninsured patients are eligible to receive the COVID-19 vaccine at no cost to them. Vaccines are covered by the federal government and providers can submit claim information to the Provider Relief Fund for reimbursement of administration at Medicare rates. The Relief Fund portal can be found here: https://coviduninsuredclaim.linkhealth.com/

(https://www.hrsa.gov/CovidUninsuredClaim)

APhA Guidance for Reimbursement: https://s3.amazonaws.com/filehost.pharmacist.com/CDN/APhACOVIDHRSAUninsuredPrgm_0621_web.pdf?AWSAccessKeyId=AKIAYICBVAN2V7IWVG4T&Expires=1655737932&Signature=12%2BscdlyfUuklCaGYXLQJ2JlClk%3D

Using an NPI Number to Order and Administer COVID-19 Vaccine

COVID-19 vaccines administered by a pharmacy require the NPI of the ordering provider and the NPI of the pharmacy. Pharmacists may need a Type 1(Individual) NPI number to order or prescribe the vaccine, or submit claims for immunization services provided by a pharmacist. For prescriptions initiated by a pharmacy, the pharmacist’s Type 1 NPI should be submitted as the Prescriber ID. To apply for or lookup an NPI number, visit https://npiregistry.cms.hhs.gov/ .

Reimbursement Using NPI Number

In order to receive Part B reimbursement for vaccination administration, the pharmacy must have an NPI, apply for Medicare Part B Provider Status (CMS Form 855I), and apply for Mass Immunization Provider Status (CMS Form 855B).

NCPA COVID-19 Vaccine Billing and Reimbursement: https://ncpa.org/sites/default/files/2020-12/COVID-19-vaccine-billing-for-NCPA_Members.pdf

How to Document

Vaccine claims submitted to a patient’s prescription benefit should include the 11-digit NDC of the vaccine given and all other relevant information regarding the specific vaccine given. Some insurers also require diagnosis and service codes to be used for billing purposes. Documentation for this billing method should be maintained in the same way that prescriptions are billed. It is recommended that pharmacies keep documentation for the health plans they have contracts with. Pharmacies should also keep records of what billing and service codes are used to request coverage and reimbursement.

Like any other service offered to patients, pharmacies should document any type of billing that was used for vaccine administration. Pharmacists should also maintain documentation of their provider enrollment as provided by CMS. 

 Information From Top Health Plans