Medicare COVID-19 Vaccine Shot Payment

On March 15, 2021, CMS updated the Medicare payment rates for administering COVID-19 vaccines.

On August 12, 2021, the FDA updated the emergency use authorizations (EUAs) for the Pfizer-BioNTech and Moderna COVID-19 vaccines to authorize the use of additional doses of the vaccine for immunocompromised individuals.

On January 3, the FDA amended the Pfizer-BioNTech COVID-19 vaccine (PDF) EUA to authorize the use of third pediatric doses for 5–11-year-old solid organ transplant patients or patients with a similar level of immunocompromise.

The FDA updated the EUAs to authorize the use of a single booster dose as follows:

  • October 20, 2021: Janssen vaccine (all patients 18 years and older)
  • November 19, 2021: Moderna vaccine (all patients 18 years and older)
  • January 3, 2022: Pfizer-BioNTech vaccine (all patients 12 years and older)
Note:
The FDA amended the Pfizer-BioNTech EUA on September 22, 2021, and the Moderna EUA on October 20, 2021, to authorize the use of a single booster dose for certain populations after completion of primary vaccination with any FDA-authorized or approved COVID-19 vaccine. The FDA amended both of these EUAs again on November 19, 2021, to authorize the use of such a single booster dose for all patients 18 years and older. On December 9, 2021, the FDA amended the Pfizer-BioNTech EUA to authorize the use of the single booster dose for all patients 16 years and older. On January 3, 2022, the FDA amended the  Pfizer-BioNTech EUA to authorize the use of the single booster dose for all patients 12 years and older and third pediatric doses for 5–11-year-old solid organ transplant patients or patients with a similar level of immunocompromise.


On October 29, 2021, the FDA updated the Pfizer-BioNTech vaccine EUA to authorize a pediatric dose for patients 5-11 years old.

Medicare Payment Rates

Vaccine Medicare Payment Rates
  • COVID-19 vaccines administered on or after March 15, 2021
  • Additional doses of the COVID-19 vaccine administered to immunocompromised patients on or after August 12, 2021
  • Booster doses administered to certain patients on or after:
    • September 22, 2021: Pfizer-BioNTech vaccine
    • October 20, 2021: Moderna vaccine
  • Booster doses administered to all patients 18 years and older on or after:
    • October 20, 2021: Janssen vaccine
    • November 19, 2021: Pfizer-BioNTech vaccine
    • November 19, 2021: Moderna vaccine
  • Booster doses administered to all patients 16 years and older on or after December 9, 2021: Pfizer-BioNTech vaccine
  • Booster doses administered to all patients 12 years and older on or after January 3, 2022: Pfizer-BioNTech vaccine
  • Pediatric doses administered on or after October 29, 2021 for patients 5-11 years old and third doses for solid organ transplant patients or patients with a similar level of immunocompromise on or after January 3, 2022: Pfizer-BioNTech vaccine
  • Approximately $40 for single-dose vaccines
  • For vaccines requiring multiple doses, approximately $40 for each dose in the series, including any additional doses and booster doses
COVID-19 vaccines administered before March 15, 2021
  • $28.39 for single-dose vaccines
  • For vaccines requiring a series of 2 or more doses:
    • $16.94 for the initial dose(s) in the series
    • $28.39 for the final dose in the series 

 

These rates reflect updated information about the costs involved in administering the COVID-19 vaccine for different types of providers and suppliers and the additional resources you need to safely and appropriately administer the vaccine.

We generally implement changes to Medicare payment rates for specific services through notice and comment rulemaking. In this case, however, we implemented the payment rate changes for these specific services to respond quickly to new information during the COVID-19 public health emergency (PHE).

For COVID-19 vaccines administered before March 15, 2021, the Medicare payment rates are:

  • $28.39 for single-dose vaccines
  • For vaccines requiring a series of 2 or more doses:
    • $16.94 for the initial dose(s) in the series
    • $28.39 for the final dose in the series 

For all COVID-19 vaccine payment rates listed above, we also geographically adjust the rates based on where you administer the vaccine.

Note:

These rates don’t apply if Medicare pays you for preventive vaccines and their administration at reasonable cost (for example, federally qualified health centers, rural health clinics, and hospital-based renal dialysis facilities). Also, as indicated in the 2021 Medicare Physician Fee Schedule Final Rule, we continue to seek additional information from the public for further consideration as we review and establish payment rates for vaccine administration services during the PHE and on a longer term basis.


Get the most current list of billing codes, payment allowances and effective dates.

 

Additional Payment for Administering the Vaccine in the Patient’s Home

View the infographic (English (PDF) (Spanish (PDF) for COVID-19 vaccine administration in the home.

Effective June 8, 2021, Medicare’s additional payment amount for administering the COVID-19 vaccine in the home for certain Medicare patients is approximately $35 per dose. This payment also applies when you administer the following in the home:

  • Additional doses of the COVID-19 vaccine to certain Medicare patients on or after August 12, 2021
  • Booster doses to certain Medicare patients on or after September 22, 2021, for the Pfizer-BioNTech vaccine and October 20, 2021, for the Moderna vaccine
  • Booster doses to all patients 18 years and older on or after October 20, 2021, for the Janssen vaccine and November 19, 2021, for the Pfizer-BioNTech and Moderna vaccines
  • Booster doses to all patients 16 years and older on or after December 9, 2021, for the Pfizer-BioNTech vaccine
  • Booster doses to all patients 12 years and older on or after January 3, 2022, for the Pfizer-BioNTech vaccine
  • For patients 5-11 years old, pediatric doses on or after October 29, 2021, or third doses for solid organ transplant patients or patients with a similar level of immunocompromise on or after January 3, 2022, for the Pfizer-BioNTech vaccine

Medicare will pay approximately $35 in addition to the standard administration amount (approximately $40 per COVID-19 vaccine dose), for a total payment of approximately $75 for a vaccine dose administered in a patient's home. We also geographically adjust the additional amount and administration rate based on where you administer the vaccine.

We established this payment amount of approximately $35 on a preliminary basis to ensure access to COVID-19 vaccines during the PHE. We continue to evaluate the needs of Medicare patients and these policies, and we'll address them in the future, as needed.

 

When Can I Get the Additional In-Home Payment for Administering the COVID-19 Vaccine?

You can get the additional payment for administering the COVID-19 vaccine in Medicare patients’ homes when either of these situations applies:

  • The patient has difficulty leaving the home to get the vaccine, which could mean any of these:
    • 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 paid or unpaid caregiver
    • They have a condition that makes them more susceptible to contracting a pandemic disease like COVID-19
    • 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 requirements under the Medicare home health benefit, you or another allowed practitioner don’t need to certify that the Medicare patient is homebound, but you must document in the patient’s medical record their clinical status or the barriers they face to getting the vaccine outside the home.

 

What Locations Qualify for the Additional In-Home Payment?

Many types of locations can qualify as a Medicare patient’s home for the additional in-home payment amount, such as:

  • A private residence
  • Temporary lodging (for example, a hotel or motel, campground, hostel, or homeless shelter)
  • An apartment in an apartment complex or a unit in an assisted living facility, group home or non-Medicaid nursing facility
  • A Medicare patient’s home that’s made provider-based to a hospital during the COVID-19 PHE
  • Effective August 24, 2021, communal spaces of a multi-unit or communal living arrangement
  • Effective August 24, 2021, assisted living facilities participating in the CDC’s Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program
Note:

In response to the COVID-19 PHE, CMS issued several 1135 waivers (PDF) to let hospitals provide services, including administering vaccines, in temporary expansion sites. CMS doesn’t pay for preventive vaccine administration under the Outpatient Prospective Payment System (OPPS) or the Physician Fee Schedule (PFS). So, we pay hospitals to administer COVID-19 vaccines at the same rate even in a non-excepted off-campus provider-based department (PBD), including a patient’s home that is made provider-based to a hospital during the COVID-19 PHE.

 

These locations don’t qualify as a home for the additional payment amount:

  • Prior to August 24, 2021, communal spaces of a multi-unit living or communal arrangement
  • Hospitals (except when the Medicare patient’s home has been made provider-based to a hospital during the COVID-19 PHE)
  • Medicare skilled nursing facilities (SNFs) and Medicaid nursing facilities, regardless of whether they’re the patient’s permanent residence

 

What Other Restrictions Apply?

Medicare only pays the additional amount for administering the COVID-19 vaccine in the home if the sole purpose of the visit is to administer a COVID-19 vaccine. Medicare doesn’t pay the additional amount if you provide another Medicare service in the same home on the same date. In those situations, Medicare pays for administering the COVID-19 vaccine at the standard amount (approximately $40 per dose).

If you administer the COVID-19 vaccine to more than 1 Medicare patient in a single home in the same multi-unit or communal living arrangement on the same day, Medicare pays:

  • Approximately $40 to administer each dose of the COVID-19 vaccine, including additional doses and booster doses
  • For dates of service between June 8, 2021 and August 24, 2021, Medicare pays the additional payment amount of approximately $35 only once per date of service in that home regardless of how many Medicare patients receive the vaccine
  • Effective on August 24, 2021, Medicare pays the additional payment amount (approximately $35 per dose administered), for up to a maximum of 5 vaccine administration services per home unit or communal space within a single group living location; but only when fewer than 10 Medicare patients receive a COVID-19 vaccine dose on the same day at the same group living location. When 10 or more Medicare patients receive a COVID-19 vaccine dose at a group living location on the same day, the additional payment can only be billed once per home (whether the home is an individual living unit or a communal space).

For example, if you administer a COVID-19 vaccine on the same date between June 8, 2021 and August 24, 2021 to 2 Medicare patients in the same home, Medicare pays approximately $115 ($35 for the in-home vaccine administration, plus 2 x $40 for each dose of the COVID-19 vaccine).

Effective August 24, 2021, if you administer a dose of the COVID-19 vaccine on the same date to 2 Medicare patients in the same home, Medicare pays approximately $150 (2 x $35 for the in-home vaccine administration, plus 2 x $40 for each dose of the COVID-19 vaccine). Similarly, effective August 24, 2021, if you administer a dose of the COVID-19 vaccine on the same date to 9 Medicare patients in the same home (including a communal space in a group living setting), Medicare pays approximately $535 (5 x $35 for the in-home vaccine administration, plus 9 x $40 for each dose of the COVID-19 vaccine). Similarly, effective August 24, 2021, if you administer a dose of the COVID-19 vaccine on the same date to 12 Medicare patients in the same home (which could be an individual living unit or a communal space in a group living location), Medicare would pay approximately $515 (12 x $40 for each dose of COVID-19 vaccine, and 1 x $35 for one in-home vaccine administration –  only one home add-on payment is billable in this circumstance because 10 or more Medicare patients were vaccinated at the same group living location on the same date). If you instead administer a dose of the COVID-19 vaccine on the same date to 12 Medicare patients in 12 different homes (i.e. each one administered in a distinct individual living unit or communal space of a group living location), Medicare would pay approximately $900 (12 x $40 for each dose administered, and 12 x $35 for each in-home vaccine administration). Similarly, effective August 24, 2021, if you administer a dose of the COVID-19 vaccine on the same date to 5 Medicare patients in a communal space in a group living setting and to 3 additional Medicare patients in their individual rooms, Medicare would pay approximately $600 (5 x $35 for the in-home vaccine administration services in the single communal space, plus 3 x $35 for each of the in-home vaccine administration services in individual homes, plus 8 x $40 for each dose of the COVID-19 vaccine).

Page Last Modified:
01/25/2022 11:56 AM