CMS Expands Medicare Payments for At-Home COVID-19 Vaccinations

Regulation | August 25, 2021 | by Juliana Bilowich

The Centers for Medicare & Medicaid Services (CMS) is expanding opportunities for people to receive COVID-19 vaccinations in their home. The move will help smaller and rural aging services providers - including affordable housing and home and community based services providers - gain access to first, second, and third doses of the vaccine for people who are at-risk or have difficulty leaving the home. 

On August 24, the Centers for Medicare & Medicaid Services (CMS) announced additional payments to healthcare providers who administer doses to multiple older adult residents in an at-home setting. The announcement comes as the country grapples with a surging COVID-19 variant and a renewed push by the Biden-Harris Administration to increase vaccinations and improve health equity. 

The expanded payment policy aims to incentivize healthcare providers to bring the vaccine to older adults in small group settings who have difficulty leaving their homes or are otherwise hard-to-reach. While many older adults are able to access a COVID-19 vaccination at a retail pharmacy or from a healthcare provider in the broader community, at-risk individuals face additional barriers access these vaccination settings.

Healthcare providers can now receive up to five additional payments for administering vaccines to a group of Medicare beneficiaries at home, instead of the previous cap of one extra payment per visit to the at-home setting, which includes smaller group homes, assisted living communities, affordable senior housing communities, and other similar settings. The extra payment amount is only available if fewer than ten Medicare beneficiaries receive a dose on the same day at the same location, which will incentivize mobile vaccine clinics at smaller provider settings. 

The policy change also expands the locations that qualify for the additional payment amount to include the communal spaces of a multi-unit community. This policy change will benefit affordable housing providers specifically, who tend to host mobile vaccine clinics in their common areas. 

CMS said the goal of the initiative is to boost the administration of the COVID-19 vaccination for smaller communal living settings; LeadingAge strongly supports the policy change to help ensure that older adults who are at-risk or have difficulty leaving their homes have equitable opportunities for vaccine access. 

Expanded Payments for Vaccine Administration At-Home

Previously this summer, Medicare increased the total payment amount for at-home vaccination from approximately $40 to approximately $75 per vaccine dose, in certain circumstances. Under CMS's new policy announced August 24, providers administering the vaccine can receive the increased payment up to five times when fewer than 10 Medicare beneficiaries get the vaccine on the same day in the same home or communal setting. 

The new policy will help healthcare providers offset additional costs related to mobile vaccine storage, temperature management, handling, and other unique challenges related to administering a COVID-19 vaccination to an access-challenged older adults in their homes. The additional payment amount also accounts for the clinical time needed to monitor a vaccine recipient after the vaccine is administered. 

The standard and additional in-home payment rate for administering each COVID-19 vaccine dose is calculated using a geographical adjustment based on where the vaccination takes place.

Applicability of Additional In-Home Payments

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

  • The individual 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 individual 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 individuals face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving.

Locations Qualifying for the Additional In-Home Payment

CMS's new announcement expands the locations that qualify as a Medicare beneficiaries home for the additional in-home payment amount. 

  • 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

Booster Shots in Smaller Aging Services Settings

COVID-19 booster shots are expected to gain FDA approval and CDC recommendation for administration beginning in the fall. Because the CDC will NOT be coordinating on-site clinics for longterm care providers, many affordable housing, HCBS, assisted living, and other non-nursing home settings serving older adults are beginning to reach out directly to pharmacies to organize booster shot access for vaccinated older adults they serve. 

While some pharmacies have indicated their intention to set up booster shot clinics on-site at various LeadingAge member provider communities, some pharmacies have established a minimum number of doses to be administered, creating a challenge for smaller providers. The new CMS policy of expanded payments for at-home vaccinations for groups of up to 10 Medicare beneficiaries may help change the approach and enable more booster shot (and first and second dose) access for smaller aging services settings.