September 21, 2021
Updated September 30, 2021
Effective for dates of service on or after June 8, 2021, Medi-Cal will reimburse providers an additional $35.00 per dose when administering a Coronavirus Disease 2019 (COVID-19) vaccine in the home of a Medi-Cal beneficiary who is unable to travel to a vaccination site. This supplemental rate is to be in addition to the $40.00 maximum allowable reimbursement currently in effect for each COVID-19 vaccine. Current reimbursement rates and billing instructions regarding each of the COVID-19 vaccines is located on the following web pages:
The supplemental Medi-Cal reimbursement is only applicable if the sole purpose of the visit is to administer a COVID-19 vaccine. The additional amount is not reimbursable if another service, separate from the administration of a COVID-19 vaccine, is provided in the same home on the same date of service. In the instance of another service being a part of the visit, Medi-Cal will only reimburse the COVID-19 vaccine administration based on the base maximum allowable reimbursement and will not apply the supplemental rate. The supplemental home administration fee is designed to target Medi-Cal beneficiaries that have difficulty leaving the home to get the vaccine, which could mean any of these:
- They have a condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver
- They have a condition that makes them more susceptible to contracting a pandemic disease like COVID-19
- They are generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort
- The patient is hard-to-reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home.
For dates of service between June 8, 2021, and August 23, 2021, if a provider administers the COVID-19 vaccine to more than one beneficiary in a single home on the same day, Medi-Cal will reimburse the additional $35.00 reimbursement only once per date of service in that home.
- For example, if a provider administers a single-dose vaccine on the same date to two Medi-Cal patients in the same home, Medi-Cal will reimburse one payment of $35.00 for the in-home vaccine administration rate, plus $40.00 for each dose of the COVID-19 vaccine administered. The total reimbursement in this scenario would be $115.00.
For dates of service on or after August 24, 2021, if the vaccine is administered to fewer than 10 Medi-Cal beneficiaries on the same day residing in the same home, Medi-Cal will reimburse up to a maximum of five times when multiple Medi-Cal patients are vaccinated in the same home.
- For example, if a provider administers six vaccines to Medi-Cal patients in the same home, Medi-Cal will reimburse five payments of $35.00 for the in-home vaccine administration rate, plus $40.00 for each dose of the COVID-19 vaccine administered. For a total reimbursement of $415.00.
Locations that can qualify as a patient’s home for the additional in-home payment amount, includes, but is not limited to, the following:
- A private residence
- Temporary lodging (for example, a hotel or motel, campground, hostel, or homeless shelter)
- An apartment in an apartment complex or a unit in an assisted living facility or group home
- When the patient’s home has been made provider-based to a hospital during the COVID-19 Public Health Emergency (PHE)
However, the following locations are not considered “homes” that can qualify for the additional payment amount:
- Communal spaces of a multi-unit living arrangement
- Hospitals (except when the Medicare patient’s home has been made provider-based to a hospital during the COVID-19 PHE)
- Skilled nursing facilities (SNFs), regardless of whether they are the patient’s permanent residence
- Assisted living facilities participating in the CDC’s Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program
How to Bill
Medical and Outpatient providers should denote this additional service on the same claim as the vaccine administration, using HCPCS code M0201 (COVID-19 vaccine administration inside a patient’s home; reported only once per individual per date of service when only COVID-19 vaccine administration is performed at the patient’s home).
Pharmacy providers should denote this additional service on the same claim as the vaccine administration, using NDC 99999999995.
Providers who administered a COVID-19 vaccine in a beneficiary’s home but did not originally submit vaccine administration claims with this billing instruction are instructed to submit a separate claim for applicable dates of service.
Additional information regarding these updates can be found in the Immunizations section in Part 2 of the Medi-Cal Provider Manual.