What is the new payment amount and what restrictions apply?

The additional payment is $35 dollars on top of the $40 dollar rate that any Medicare provider giving the vaccine can get for a total of $75 dollars for a single dose or $150 dollars for the administration of both doses of the two dose vaccines. This add-on payment and administration rates are geographically adjusted.

Medicare will only pay this 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 will not pay the additional amount if 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 a provider administers the COVID-19 vaccine to more than 1 Medicare patient in a single home on the same day (such as a patient and his/her caregiver), Medicare pays:

• The additional payment amount of approximately $35 only once per date of service in that home
• Approximately $40 to administer each dose of the COVID-19 vaccine

For example, if a provider administers a single-dose vaccine on the same date 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).

Which beneficiaries qualify the provider for the extra payment?

Providers can get this additional payment for administering the COVID-19 vaccine in Medicare beneficiaries’ when either of the following two situations are documented in the beneficiary’s medical record:

• 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-1
  • 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, providers do NOT need to certify that the Medicare patient is homebound but do need to document in the medical record either the clinical status or the barriers they face getting the vaccine outside the home.

What locations qualify as “home”

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

• 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 (with the exception of those who participated in the CDC LTC Pharmacy Partnership) or group home
• A Medicare patient’s home that’s made provider-based to a hospital during the COVID-19 public health emergency

The following locations DO NOT qualify as a home for the purposes of receiving the additional payment amount

• Communal spaces of a multi-unit living arrangement 
• Hospitals, Medicare and Medicaid SNFs, regardless of whether they are the beneficiary’s permanent residence
• Assisted living facilities whose residents were vaccinated through the CDC Pharmacy Partnership for Long Term Care