April 04, 2022
In March 2021, the California Department of Health Care Services (DHCS) submitted a State Plan Amendment (SPA 21-0020) to the Centers for Medicare and Medicaid Services (CMS) for coverage and reimbursement of COVID-19 vaccine administration services provided by Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC) and Tribal RHCs. DHCS had requested approval to reimburse COVID-19 vaccine administration services at the Medicare payment rates, currently $40 per shot.
On March 2, 2022, CMS approved SPA 21-0020, but with a required reimbursement rate of $67 per shot for services rather than the proposed $40 rate. The reimbursement rate is retroactive to November 2, 2020. Until further clarification is provided and the DHCS systems are prepared to process claims, per DHCS guidance, it is recommended that FQHCs and RHCs hold claims for vaccine-only administration if the encounter does not meet the requirements of a billable visit.
The California Medical Association (CMA) is working with DHCS to identify when the Medi-Cal claims system will be ready to process and pay affected COVID-19 vaccine admin services. Additionally, CMA has inquired about potential timely filing issues that health centers may encounter and whether claims submitted to date will be automatically reprocessed at the $67 per shot rate.