December 18, 2020
Area(s) of Interest: Public Health Public Payors
On Friday, December 18, the Department of Health Care Services (DHCS) announced its plan for reimbursement of the administration of the COVID-19 vaccine.
According to the announcement, DHCS will follow Medicare policy and reimburse physicians for COVID-19 vaccine administration at Medicare rates. Consistent with the approach taken by Medicare for Medicare Advantage Plans, DHCS is also carving out the COVID-19 vaccine administration reimbursement from the Medi-Cal managed care system and will reimburse under the fee-for-service (FFS) delivery system for both medical and pharmacy claims. DHCS states this approach will ease program administration, eliminate challenges with out-of-network provider reimbursements and keep vaccine administration fee rates consistent for providers regardless of delivery system.
To avoid delays and denials in payment, physicians will need to ensure claims for COVID-19 vaccine administration are submitted to Medi-Cal FFS rather than the Medi-Cal managed care plans. Because the federal government is supplying the vaccine itself at no cost, physicians should not bill for the vaccine itself at this time.
Federally qualified health centers, rural health clinics and Tribal 638 clinics will be able to bill for COVID-19 vaccine administration outside of their current Prospective Payment System or All-Inclusive Rate.
For more information on Medicare payment allowances and effective dates for COVID-19 vaccines and administration during the Public Health Emergency, click here.
DHCS is in the process of updating its systems to pay at the Medicare rates. Until then, physicians are advised to hold COVID-19 vaccine administration claims. DHCS expects the system to be updated and ready to accept vaccine administration claims sometime in January. The California Medical Association will share this information as soon as it is available.
DHCS will be seeking federal approval to cover the cost of vaccine administration for Medi-Cal beneficiaries who are in restricted scope coverage, the COVID-19 uninsured population and enrollees of the Family Planning, Access, Care, and Treatment (Family PACT) program.
DHCS plans to submit all federal waiver requests today and will start to issue policy guidance on COVID-19 vaccine administration and reimbursement by December 25, 2020. For more information, click here.