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On May 3, 2021, the U.S. Department of Health & Human Services (“HHS”) announced the creation of the COVID-19 Coverage Assistance Fund (“CAF”).[i] Providers who administered the vaccine to patients on or after December 14, 2020 can now seek reimbursement for certain amounts they were unable to bill to patients for with administering the vaccine.
For providers to administer a COVID-19 vaccine, providers must be enrolled in the CDC COVID-19 Vaccination Program. As of February 2021, the CDC requires participating providers to administer a COVID-19 vaccine without regard to a patient’s ability to pay and at no additional cost to the patient. This means that a patient cannot be charged if the patient is uninsured,[ii] underinsured, is out of network, or has a cost-sharing amount (e.g., co-pays, deductibles, or co-insurance). While the CARES Act requires some insurance payors to cover COVID-19 related items and services at no additional charge to patients, not all insurance payors are subject to this requirement. Therefore, some insurance payors may not cover COVID-19 vaccines and/or may impose cost-sharing on patients.
The CAF is intended to relieve providers of some of the costs of administering a COVID-19 vaccine to underinsured patients and it will allow providers to obtain reimbursement for eligible vaccination services at the national Medicare rates in effect at that time the vaccination was administered.[iii]
The CAF will only reimburse a provider for administering a COVID-19 vaccine to the patient. If a provider only gives the patient a COVID-19 vaccine, no other fees can be billed for that patient visit (such as an office visit fee).[iv] Before the provider is eligible to seek reimbursement from the CAF, the provider must first submit a claim to the patient’s health care insurer and receive a denial or partial payment. Providers must also verify that the patient has no other payor to cover the cost or cost-sharing portion of a COVID-19 vaccine.
By submitting for reimbursement with the CAF, the provider agrees to accept program reimbursement as payment in full and that the provider will not balance bill the patient. The provider will also be subject to all terms and conditions of the CAF,[v] including the possibility of post-reimbursement audits. All coverage determinations are final; if the CAF claim is denied, the provider has no appeal options.
Providers can only submit claims to the CAF for authorized COVID-19 vaccines. If prior to February 2021, the provider-billed patients for vaccinations being submitted to the CAF, they are required to notify those patients that they now owe nothing for the vaccination services. If providers received payments from individuals and submit a claim for reimbursement to the CAF, the provider must reimburse the patient for all amounts paid. All CAF claims must be submitted by providers within 365 days of the service date and are subject to availability of program funding.
[iv] https://www.cdc.gov/vaccines/covid-19/vaccination-provider-support.html (last visited May 6, 2021).
[v] Supra n. 3.
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