Medicare adds bonus for some at-home COVID-19 vaccine administrations

The Centers for Medicare & Medicaid Services (CMS) announced last week it is increasing Medicare payment for administration of COVID-19 vaccines in the homes of certain patients.

Effective June 8, Medicare will pay an additional $35 per dose for at-home administration of the COVID-19 vaccine in either of these situations:

1. The patient has difficulty leaving home to get the vaccine, because:

• They have a condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a caregiver (paid or unpaid),
• They have a condition that makes them more susceptible to contracting a pandemic disease like COVID-19,
• They are generally unable to leave the home, and if they do leave home, it requires a considerable and taxing effort.

2. The patient is hard-to-reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home. These patients face challenges (e.g., with transportation, communication, or caregiving) that significantly reduce their ability to get vaccinated outside the home.

Unlike the requirements for Medicare’s home health benefit, you don’t need to certify the Medicare patient is homebound, but you must document in the patient’s medical record their clinical status or the barriers they face in getting the vaccine outside the home.

Per CMS, examples of a Medicare patient’s home for the additional in-home payment amount include:

• A private residence,
• Temporary lodging (e.g., a hotel or motel, campground, hostel, or homeless shelter),
• An apartment in an apartment complex or a unit in an assisted living facility or group home,
• A Medicare patient’s home that has been made a provider-based department of a hospital during the COVID-19 public health emergency

However, the following locations do not qualify for the additional payment amount:

• Communal spaces of a multi-unit living arrangement,
• Hospitals, Medicare skilled nursing facilities, and Medicaid nursing facilities, regardless of whether they are the patient’s permanent residence,
• Assisted living facilities participating in the Centers for Disease Control and Prevention’s Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program.

When added to the standard administration rate (approximately $40 per dose), the new bonus creates a total payment of approximately $75 for a single-dose COVID-19 vaccine or $150 for both shots in a 2-dose series (with some variation based on CMS’ geographical adjustments).

Medicare only pays the additional amount for administering the COVID-19 vaccine if the sole purpose of the home visit is to administer the vaccine. Medicare doesn’t pay the additional amount if you provide another Medicare service in the same home on the same date. In those situations, Medicare only pays the standard vaccine administration amount.

Also, Medicare only pays the additional amount once per date of service per home. If you administer the COVID-19 vaccine to more than one Medicare patient in a single home on the same day, Medicare pays the additional amount just once. So, if you administer a single-dose vaccine on the same date to two Medicare patients in the same home, Medicare would pay approximately $115 ($35 for the in-home vaccine administration, plus 2 x $40 for each dose of the COVID-19 vaccine).

Use the HCPCS Level II code M0201 to report the additional payment rate for administering the COVID-19 vaccine in the home. For more information, please visit the CMS website and view the related infographic.

— Kent Moore, Senior Strategist for Physician Payment