BriggsNetNews

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

July 13, 2023 … CMS Administrator Brooks-LaSure Letter to Payors Regarding Coverage of COVID-19 Vaccines Post Commercialization

To Medicare Plans, Private Insurance Plans, and State Medicaid and CHIP Programs:

Thank you for your continued efforts to address the effects of COVID-19, even after the end of the COVID-19 Public Health Emergency (PHE) declared under the Public Health Service Act. As we look toward efforts to provide updated COVID-19 vaccines this fall, we know you may have questions about the shift away from U.S. Government purchasing of vaccines to a more traditional commercial market. To be clear, that shift has not yet occurred, and the currently authorized and approved COVID-19 vaccines continue to be free and widely available nationwide. We also wanted to send these reminders from the Centers for Medicare & Medicaid Services (CMS) about COVID-19 vaccine coverage and encourage you to start planning now for the fall vaccination campaign.

By law, any Food and Drug Administration (FDA)-approved or authorized COVID-19 vaccine is covered under Medicare Part B. Medicare is also required by law to cover COVID-19 vaccinations without cost-sharing. These requirements were added by the Coronavirus Aid, Relief, and Economic Security (CARES) Act. Medicare Advantage plans are required to cover the same benefits covered by Medicare Parts A and B. Plans should begin preparing now to ensure that their systems are ready by mid-to-late September to support administration of the updated COVID-19 vaccines.

Under statutory amendments made by the American Rescue Plan Act (ARP), states are currently required to cover COVID-19 vaccines and their administration, without cost-sharing, for all Children’s Health Insurance Program (CHIP) beneficiaries and nearly all Medicaid beneficiaries, through the last day of the first calendar quarter that begins one year after the last day of the COVID-19 emergency period (the last day of “the ARP coverage period”), which is September 30, 2024. Through that same day, the federal government will match state expenditures on COVID-19 vaccine doses and vaccine administration at 100 percent, which means that the states’ payments on these services will be fully federally matched. 

After the government ceases to supply COVID-19 vaccines from its current stock for most children enrolled in Medicaid, the cost of COVID-19 vaccine doses is expected to be borne by the Vaccines for Children (VFC) program. For other Medicaid populations, and for beneficiaries enrolled in CHIP, states would have to pay for COVID-19 vaccine doses after the government ceases to supply doses, but states’ payments on those doses will be federally matched at 100 percent until September 30, 2024. After September 30, 2024, state expenditures on COVID-19 vaccine doses and vaccine administration services would be matched at the applicable state federal medical assistance percentage. Vaccine doses covered under the VFC program would still be fully federally funded. After September 30, 2024 (the last day of the ARP coverage period), Medicaid coverage of COVID-19 vaccines and their administration will vary for different groups of beneficiaries. For example, beginning October 1, 2023, under amendments made by the Inflation Reduction Act, most adults enrolled in Medicaid and CHIP will have mandatory coverage of all approved vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), and the administration of those vaccines, without cost -sharing. This would include all FDA-approved ACIP-recommended COVID-19 vaccinations but would not include COVID-19 vaccinations authorized under an FDA emergency use authorization (EUA). That said, COVID-19 vaccinations authorized under an EUA are included in the coverage states are required to provide under the ARP until September 30, 2024.

Finally, most private health insurance, like employer-sponsored plans, Marketplace plans, and other individual market coverage that is subject to the Affordable Care Act (ACA) market reforms are required to cover vaccines for COVID-19 authorized for emergency use or approved by the FDA and recommended by the ACIP and their administration, without patient cost-sharing. Again, you should start planning now to make sure systems are prepared.

At CMS, we stand ready to assist with any concerns you may have and want to work together to make sure the fall COVID-19 vaccination campaign is a success.

Signed Administrator Brooks-LaSure