How are the reimbursement rates determined? (uninsured)

Reimbursement pricing and policies under this program for eligible services, as determined by HRSA (subject to adjustment as may be necessary), are described below.

• Reimbursement is based on the current year Medicare fee schedule rates except where otherwise noted.
• Publication of new codes and updates to existing codes is made in accordance with published CMS guidance.
• For any new codes where a CMS published rate does not exist, claims are held until CMS publishes corresponding reimbursement information.
• Claims submitted electronically for professional services are priced as follows:
  • Services are priced with current-year CMS pricing with geographic adjustments, as applicable.
  • If no geographic adjustments are applicable, services are priced with current-year CMS national pricing.
  • COVID-19 testing and specimen collection procedures are priced in accordance with CARES Act (PDF) requirements and rates published in CMS interim final rules.
• Claims submitted electronically for facility services are generally priced according to traditional Medicare reimbursement, examples of exceptions are noted below:
  • For purposes of this program, facility reimbursement based on IPPS does not include the 20% increase to the DRG weight for COVID-19 diagnoses U07.1 and B97.29 authorized by Section 3710 of the Cares Act.
  • For purposes of this program, reimbursement rates for facilities not paid on IPPS [Critical Access Hospitals (CAHs), Rural Health Clinics (RHCs), Children’s Hospitals, and PPS Exempt Cancer Hospitals] are not updated after February 4, 2020.
  • Home health services are priced based on a per-visit methodology by service type as established by the program:
    • All Medicare-eligible service categories: PT/OT/ST - $90
    • Nursing services – skilled nursing - $90
    • Nursing services – licensed practical nurse - $60
    • Medical social services - $90
    • Home health aide - $30
    • Home infusion therapy – PICC/midline supplies $70, PICC/midline placement $110
• For purposes of this program, the following rates apply for reimbursement of ambulance claims with a primary diagnosis of COVID-19:
  • Ground ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Water ambulance: facility price of $350 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
  • Air ambulance: facility price of $2,300 per claim; professional claims price at current year CMS pricing with geographic adjustments as applicable
• The dispensing fee for FDA-licensed or authorized outpatient antiviral drugs for treatment of COVID-19 is priced at $12 without geographic adjustment.

FDA-licensed or authorized vaccine administration fees are priced based on national Medicare rates and are outlined below. For guidance on eligibility and billing for vaccine administration, refer to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) websites.

• For dates of service through March 14, 2021:
  • Administration of the final dose of a COVID-19 vaccine requiring a series of two or more doses - $28.39
  • Administration of the first dose of a COVID-19 vaccine requiring a series of two or more doses - $16.94
  • Administration of a single-dose COVID-19 vaccine - $28.39
• For dates of service on or after March 15, 2021:
  • Administration (per dose) of a COVID-19 vaccine - $40.00
  • For guidance on eligibility and billing for booster shots and additional doses of the vaccine, refer to the CDC website.
• For COVID-19 vaccinations administered in-home* with dates of service on or after June 8, 2021:
  • Administration (per dose) of a COVID-19 vaccine - $75.50
  • For guidance on eligibility and billing for booster shots and additional doses of the vaccine, refer to the CDC website.
  • *Note: In-home vaccine administration claims must be submitted with two codes to be eligible for reimbursement:
    • The first code must be one of the following:
      • Pfizer: 0001A, 0002A, 0003A, 0004A, 0071A, 0072A, 0073A
      • Moderna: 0011A, 0012A, 0013A, 064A
      • Janssen: 0031A, 0034A
    • The second code must be M0201 (COVID-19 vaccine home administration)
    • For a definition of what constitutes in-home administration, see this CMS fact sheet (PDF - 138 KB).