Medicare Creates Additional Payment for At-Home COVID-19 Vaccine Administration

Effective June 8, 2021, Medicare will pay an additional $35 per dose for administering the COVID-19 vaccine in the home for certain Medicare patients that have difficulties leaving their homes or are hard-to-reach. This $35 dollar payment is in addition to the standard payment for vaccine administration, which varies based on location but is approximately $40 per dose. The additional payment also applies to each dose of a two-dose vaccine if both doses are administered in the home. To be eligible for the at-home additional payment, both the location and the beneficiaries must be certain criteria.

Private residences, temporary lodging, apartments, most units in an assisted living facility (ALF) or group home, and the homes of Medicare beneficiaries have been made provider-based to a hospital during the COVID-19 public health emergency generally qualify as location eligible for the at-home additional payment. However, hospitals, skilled nursing facilities (SNFs), some ALFs, and the communal spaces of apartment buildings or group homes do not qualify for the at-home additional payment.

In addition, to an eligible location, the Medicare beneficiaries must also meet certain criteria. Specifically:

• The patient has difficulty leaving the home to get the vaccine, meaning:
  • 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 caregiver;
  • They have a condition that makes them more susceptible to contracting a pandemic disease like COVID-19; or
  • 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. These patients face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving.

Unlike the Medicare home health benefit, the provider need not certify homebound status. However, the provider must document in the patient’s medical record their clinical status or the barriers they face to getting the vaccine outside the home.

Lastly, Medicare will only pay the at-home additional amount if the sole purpose of the visit to the beneficiary’s home is to administer a COVID-19 vaccine. If the provider visits the home to provide another Medicare service and also administers the vaccine, this administration is not eligible for the at-home additional payment. Further, if two or more beneficiaries share the same home and a provider visits the home and administers the vaccine to all beneficiaries during the single visit, Medicare will only pay a single at-home additional payment.

For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in understanding new developments in healthcare regulation. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney  at 248-544-0888 or wapc@wachler.com.