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State Issues Medicaid Coverage Policy and Billing Guidance for COVID-19 Vaccine Administration

The Department of Health (DOH) has issued guidance for Medicaid coverage for providers administering the COVID-19 vaccine. This policy is in effect for the remainder of the disaster emergency declared by Executive Order (EO) 202 issued by Governor Cuomo.

As additional COVID-19 vaccines become available under an emergency use authorization (EUA) or are otherwise approved by the Food and Drug Administration (FDA), the billing guidance will be updated. The policy applies to both Medicaid fee-for-service (FFS) and Medicaid Managed Care (MMC). New York State Medicaid will not reimburse for the cost of the vaccine itself, as it is free to providers.

The guidance indicates that providers must not bill Medicaid for the administration of the COVID-19 vaccine to members who are also enrolled in Medicare. Dually eligible enrollees will continue to access full coverage of immunization services through Medicare. Medicare rates for COVID-19 vaccination are available here.

Billing guidance for various hospital and Federally Qualified Health Center (FQHC) settings, pharmacies, and long term care providers is listed. The guidance clarifies that reimbursement of the administration fee is in addition to the rate (i.e., per diem, per visit, per hour) reimbursed to the provider and must be billed to Medicaid separately. Rate-based providers may also bill for COVID-19 vaccine administration on a stand-alone claim when other services are not provided.

For individuals enrolled in MMC, providers should check with the individual’s MMC Plan for implementation details, reimbursement fees, and billing instructions. Plans and providers may negotiate a reasonable rate for COVID-19 vaccine administration to ensure member access to providers qualified to administer COVID-19 vaccines.

Contact: Meg Everett, meverett@leadingageny.org, 518-929-9342