Additional Guidance Addressing COVID-19 (Coronavirus) Vaccines
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Guidance for Massachusetts commercial health insurers and health maintenance organizations on facilitating member access to COVID-19 vaccines and reimbursement expectations for vaccine administration.
No material clinical or coverage changes in this revision.
Coverage and Reimbursement Expectations
Coverage and reimbursement expectations
Division expectations for carrier coverage and reimbursement of COVID-19 vaccines include the following requirements and operational practices:
Provider Billing, Cost-Sharing, and Reimbursement Rules
No member cost-sharing for COVID-19 vaccines
Carriers must forego any cost-sharing (copayments, deductibles, or coinsurance) for COVID-19 vaccinations at permitted locations, including from out-of-network providers.
- Applies to vaccinations at providers' offices, urgent care centers, hospitals, pharmacies, or other locations allowed by DPH and CDC requirements.
Reimburse above MassHealth rate for vaccine administration
Carriers must reimburse providers, whether in-network or out-of-network, for administration of COVID-19 vaccines at rates that are higher than the MassHealth reimbursement rate for the same service for any vaccine administered from January 1, 2021 onward.
- Requirement applies to both in-network and out-of-network providers.
- Effective for vaccines administered on or after January 1, 2021.
Separate reimbursement allowed when vaccine given with unrelated encounter
If a COVID-19 vaccine is administered during a full office visit, emergency department visit, or other encounter not related to COVID-19 testing/assessment/treatment, carriers are expected to reimburse for the vaccine separately if it is billed that way.
- This applies even though vaccine administration may ordinarily be bundled within reimbursement for the full office visit.
Accept Commonwealth Medicine subrogation claims and allow ≥180-day submission window
For vaccines given at temporary clinics where Commonwealth Medicine coordinates billing as the agent, carriers are expected to accept and pay all subrogation claims submitted by Commonwealth Medicine and must not impose a claims submission deadline earlier than 180 days after the administration date.
- Applicable to pop-up locations, mass vaccination sites, or public clinics hosted by state or municipal health departments.
Encourage plan sponsors to align with Bulletin provisions
Carriers acting as administrators for self-funded (employment-sponsored non-insured) plans are requested to encourage plan sponsors to follow the Bulletin's provisions and remove barriers to vaccine access.
- Carriers should inform plan sponsors about public health risks and coordinate benefits consistent with this Bulletin.
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