Originally published December 22, 2020
Updated on January 6, 2021
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 is seeking federal approval to pay Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Indian Health Service (IHS) – Memorandum of Agreement (MOA) 638 Clinics for the vaccine administration fee outside of their current Prospective Payment System (PPS) or All-Inclusive Rate (AIR).
DHCS submitted all federal waiver requests on December 18, 2020 to the federal Centers for Medicare and Medicaid Services (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
- Billing specifics for the different provider communities and program areas, including medical, outpatient, pharmacy, FQHC/RHC/IHS and FPACT, will be released in future News articles. 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 begin administration of the vaccine in accordance with the CDPH Allocation Guidelines for COVID-19 Vaccine During Phase 1A but should not submit billing until instructed to do so. This applies to all provider communities and program areas.
- System and operational changes are required to enable successful claims adjudication.
- Claims that are submitted prior to forthcoming implementation of these changes will likely be denied by default because the system is not prepared to intake these claims at this time.
- Providers will be notified when they can begin submitting claims for administration of the vaccine, as well as guidance on how to properly bill for the administration.
- 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 will enroll in the federal COVID-19 Vaccination Program electronically through CDPH’s provider registration and enrollment system at the COVIDReadi website. Enrollment is limited at this time to providers authorized by their local health department (LHD). Others may enroll later in January as vaccine supply increases. Before enrolling, providers need to obtain their immunization information system (IIS) ID at the California Immunization Record (CAIR2) website. Once providers have been invited by their LHD and have their IIS ID, they should confirm that they meet all requirements listed in the COVIDReadi Provider Enrollment Instructions before enrolling. Providers with questions about enrolling in the California COVID-19 Vaccination Program can email COVIDCallCenter@cdph.ca.gov or call (833) 502-1245, Monday through Friday, from 9 a.m. to 5 p.m.
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 recordkeeping requirements, including recording the administration of the vaccine to patients in their own systems within 24 hours and to public health data systems within 72 hours.