The Centers for Medicare and Medicaid Services (CMS) announced a plan for coverage of COVID-19 vaccines and therapeutics. Here’s what you need to know.
As expected, any vaccine approved by the Food and Drug Administration (FDA)—including those authorized under an Emergency Use Authorization (EUA) or Biologics License Application (BLA)—will be covered under Medicare/Medicare Advantage with no cost sharing.
Providers will also be prohibited from charging for administration of the vaccine.
The plan also includes provisions for private plans—implementing provisions of the CARES Act requiring coverage of a COVID-19 vaccine by most private health insurance plans without cost sharing from both in and out-of-network providers during the public health emergency.
With regards to treatments, currently, Medicare hospitals can get extra payments (outlier payments) to cover costs that exceed the bundled payments under the Medicare Severity-Diagnosis Related Group (MS-DRG) system—but outlier payments aren’t common.
According to the CMS plan, outlier calculations would be relaxed—allowing hospitals to qualify for additional payments when they treat patients with newly approved products. (We think this is a positive step, but we’re still reviewing the details.)
CMS is also proposing that therapies would be paid separately in the hospital outpatient setting—and not bundled with their related services. (Again, we’ll dig into how meaningful this is, since most therapies today are already outside the outpatient bundle.)
What’s next? The interim final rule is effective immediately until the end of the public health emergency, with a 60-day comment period.
