Originally published December 22, 2020
Updated on February 24, 2022
Most recent updates are denoted with two plus signs (++)
++The information below, originally published on December 22, 2020, has been updated. The updated information is outlined in the February 24, 2022, article titled “Providers Holding Submissions of Claims for COVID-19 Vaccine Administration May Now Submit” published on the Medi-Cal Providers website. Providers seeking the latest claim submission guidance from Medi-Cal for the populations addressed in this original article, should refer to the February 24, 2022, article.
This is the first article in a series of articles regarding COVID-19 vaccine administration and the Department of Health Care Services’ (DHCS) role in supporting the state’s vaccination efforts.
With the recent federal approval of COVID-19 vaccines, the DHCS is seeking federal approval to help support delivery of the vaccine to all Medi-Cal beneficiaries. The vaccine will be provided at no cost to all Californians. The purpose of this article is to provide an update in terms of how DHCS plans to reimburse the administration fee tied to the vaccine under Medi-Cal.
DHCS will follow California’s COVID-19 vaccination plan, which was approved by the California Department of Public Health (CDPH). It calls for implementation in several phases: Pre-vaccine; limited doses available; larger number of doses available; and sufficient supply of doses available for the entire population. For further information on the state’s vaccination planning efforts please visit https://covid19.ca.gov/vaccines/.
California is leveraging its existing immunization framework and emergency response infrastructure to coordinate efforts among state, local, and territorial authorities to administer the vaccine. Throughout this effort, DHCS will share appropriate information with you and our providers, health plan partners, counties, other key stakeholders, and beneficiaries.
Consistent with the approach being taken by Medicare through Medicare Advantage Plans, DHCS will carve out the COVID-19 vaccine from Medi-Cal managed care health plans and will reimburse providers under the fee-for-service (FFS) delivery system for both medical and pharmacy claims. 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.
Medi-Cal proposes to reimburse the associated COVID-19 vaccine administration fee at the allowable Medicare rate for all claims (medical, outpatient and pharmacy), based on the number of required doses. As the federal government will pay for the initial vaccines, there is no Medi-Cal provider reimbursement for the COVID-19 vaccine itself. Providers will bill for administration of the COVID-19 vaccine on a medical, outpatient or pharmacy claim, based on current policy. The Medicare administration rate DHCS is seeking differs from the current Medi-Cal pharmacy administration fee today. DHCS is also seeking federal approval to cover the cost of the 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.
In addition, DHCS has submitted a State Plan Amendment to request approval from the Centers for Medicare and Medicaid Services (CMS) to reimburse Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Indian Health Services-Memorandum of Agreement (IHS-MOA) 638 clinics a fee-for-service rate for vaccine administration when the encounter does not meet all of the requirements of a billable visit (i.e. vaccine-only administration). For additional updates regarding these requests for federal approvals, providers should refer to the latest guidance on the COVID-19 Medi-Cal Response page.
DHCS submitted all federal waiver requests on December 18, 2020 to CMS and has issued initial policy guidance on COVID-19 vaccine administration and our reimbursement policy. Policy and reimbursement guidance will be updated upon additional CMS guidance and/or approvals of requested waivers.
Initial Policy and Guidance
- Medi-Cal will reimburse the associated COVID-19 vaccine administration fee at the allowable Medicare rate for providers based on the number of required doses, regardless of vaccine manufacturer:
- One dose: $28.39 upon administration
- Two doses:
- $16.94 upon administration of the first dose
- $28.39 upon administration of the second dose
- Dose administrations may be billed separately, or together on the same claim, whichever fits the provider’s billing preferences and practices
- There is no requirement for the same provider to administer both doses. Each dose is separately reimbursable.
- The manufacturer of the doses administered to a Medi-Cal beneficiary must remain consistent between the first and second doses, regardless of the administering provider.
- Vaccine-specific billing instructions for the different provider communities and program areas, including medical, outpatient, pharmacy, FQHC, RHC and IHS-MOA clinics and Family PACT, will be released as they are made available, either as updates to the vaccine-specific web pages or as one-off articles on the COVID-19 Medi-Cal Response page. Providers will be expected to bill for the COVID-19 vaccine administration using the claim forms and electronic media used today, unless otherwise noted.
- Providers are encouraged to administer the vaccine in accordance with the most current CDPH Allocation Guidelines for COVID-19 Vaccine.
- Upon original publication of this article, providers were asked to hold billing until instructed to begin submitting. This applied to all provider communities and program areas. Medi-Cal can now intake and process administration of currently approved COVID-19 vaccines on all pharmacy claim submission types and most medical and outpatient claims. Part of the reason for the initial guidance was:
- System and operational changes were required to enable successful claims adjudication.
- Claims submitted prior to implementation of these changes were likely be denied by default because the system was not prepared to intake these claims at the time.
- For the most current direction regarding whether or not claims should be submitted, and what behavior to expect when submitting, providers should refer to the “Pharmacy Claim Submissions” and “Medical and Outpatient Claim Submissions” tables on the COVID-19 Medi-Cal Response page.
- DHCS is finalizing policy guidance on COVID-19 vaccine administration which will be included in future News article(s) and Managed Care All Plan letter(s).
- Policy and reimbursement guidance will be updated upon additional CMS guidance and/or approvals of requested waivers.
Pharmacies, retail clinics, providers, and any other sites of care must sign an agreement with the U.S. government to receive free supplies of the COVID-19 vaccine(s).
Under the agreement, all providers must vaccinate individuals regardless of existing health coverage or the type of coverage. Providers are prohibited from balance billing or otherwise charging vaccine recipients.
In order to receive and administer COVID-19 vaccines, all California healthcare providers should refer to the enrollment instructions on the CDPH website, email the California COVID-19 Vaccination Program at COVIDCallCenter@cdph.ca.gov or call the COVID-19 Call Center at (833) 502-1245, Monday through Friday, from 9 a.m. to 5 p.m. More information is also available on the COVID-19 Vaccine Questions and Answers web page.
Vaccine recipients must be provided with emergency use authorization fact sheets about the vaccine and vaccination cards identifying the brand of vaccine administered and the date of their second vaccination (if applicable).
Providers must administer the vaccine in accordance with the CDC and Advisory Committee on Immunization Practices requirements, and they must meet storage and State-mandated recordkeeping requirements , which for California includes recording the administration of the vaccine to patients in their own systems within 24 hours and to public health data systems within 24 hours.