Getting reimbursed for the COVID-19 vaccine: What pharmacies need to know

By Good Neighbor Pharmacy

Submitting claims doesn't have to be overwhelming

Independent pharmacies across the country are stepping up to make sure Americans are vaccinated against COVID-19. But the work doesn't stop once shots are in arms. Many pharmacists report that the most complex aspect of providing the COVID-19 vaccine is getting reimbursed for it. And while the paperwork and reporting might seem overwhelming, the process isn't all that different from what you're already used to.

The two biggest differences in the process of reimbursement for the COVID-19 vaccine are reimbursement for vaccinating uninsured patients and the sheer volume of patients you're vaccinating. This guide can help you better navigate the ins and outs of getting reimbursed for the COVID-19 vaccine.

What you need to know about billing

When you administer the COVID-19 vaccine, you'll submit a claim to Medicare, Medicaid, a commercial health plan, or a federal program for uninsured patients.

Medicare & Medicaid reimbursement

The COVID-19 reimbursement process differs depending on a patient's insurance status. Medicare and Medicaid, for example, typically reimburse $40 for each dose. In the beginning, most plans were reimbursing closer to $17 for the first shot and $28 for the second. This new, higher reimbursement rate might vary depending on whether your state has an exception that allows a lower reimbursement.
If you're billing a Medicare patient, the vaccine is covered as a Part B benefit. If you're billing through Medicaid, the specifics can vary from state to state.

Commercial plan reimbursement

Commercial health plans reimburse COVID-19 vaccinations for both in-network and out-of-network providers. This reimbursement can be part of the medical benefit, the prescription benefit, or even both, according to the NCPA's reimbursement guide. If you're choosing between medical or pharmacy benefit billing, NCPA recommends that you look into fees, workflow, reimbursement rates, and timing. Ultimately, if you find that your prescription claim isn't processing correctly, you can go back and try submitting as a medical claim.

Reimbursement for uninsured and underinsured patients

The process is a little more complicated when pharmacies seek reimbursement for vaccinating uninsured patients. To start, you'll need to sign up for the CARES Act Provider Relief Fund through the Health Resources and Services Administration (HRSA). Even pharmacies that are part of a network need to sign up for the relief fund on their own, following the steps provided by the HRSA. These steps include obtaining a One Healthcare ID, providing a Taxpayer Identification Number, setting up an Optum Pay ACH, and adding a provider roster and a patient attestation and patient roster. After this, you can submit claims electronically and bill all uninsured vaccinations directly through the program.

Pharmacies can also obtain payment for underinsured patients (individuals whose health plans do not cover COVID-19 vaccine administration or only provide partial reimbursement). To be eligible for reimbursement, you must have first submitted the claim to the individual's health plan for payment and had the claim denied or only partially paid. Visit the COVID-19 coverage assistance site to sign up.

What you need to know about submitting claims

Regardless of the plan or program reimbursing you for administering the COVID-19 vaccine, keep these tips and reminders in mind as you submit claims.

1. Always bill the $40 reimbursement rate when working with commercial plans.

Commercial insurance plans might have more variation in how much they reimburse, compared to Medicare and Medicaid. Some companies raised their reimbursements to match the $40 rate, but others are continuing to use a lower reimbursement rate. Some PBMs, meanwhile, are asking pharmacies to reprocess their claims later, once the higher rate is in place. Moving forward, no matter what rate a plan says it is using, it's still best for a pharmacy to bill at the $40 rate. If you only bill $17, you'll only get $17 — even if the PBM is paying the higher rate. But if you bill for the higher rate, then you can qualify for the higher payment if the commercial plan increases its rate. Most PBM contracts stipulate that they'll pay pharmacies the lesser of either the contract rate or the pharmacy's submitted rate.

2. All claims must be transmitted, whether you're getting paid or not.

Some pharmacy owners might find the HRSA process a bit cumbersome, to the point that they even consider not wanting to bill cash at all. However, it's important that pharmacy owners remember they must transmit all their vaccine claims, whether they're transmitting them as cash and not getting paid or they are submitting for payment.

Even if the HRSA process feels backlogged, it's vital to make sure that all claims are transmitted. Transmitting every claim is how independent pharmacies can make sure every vaccine dose they administer is accounted for, and it can fulfill some of the CDC's reporting requirements. This reporting tells the data-driven story of just how quickly and efficiently independents are able to vaccinate and deliver care in their communities.

3. Your pharmacy management system can help with some issues. 

If you're having trouble with a claim not being billed correctly, your pharmacy management system vendor can often help you fix those issues. This is an untapped resource that many pharmacy managers might forget is available to them. Just contact someone in the support department and tell them about the issue you're encountering. They're ready to help pharmacies navigate and troubleshoot issues around coding and submitting claims.

4. Receiving payments may take time.

If it takes some time for your pharmacy to get reimbursed for the COVID-19 vaccine, remember that this isn't unusual. Many pharmacies don't receive reimbursements right away, especially since the vaccine rollout process was slower, with more limited availability at first. Only recently has the entire American adult population become eligible for vaccines.

Administering the COVID-19 vaccine — and the claims and reporting that go along with it — gives independent community pharmacies an opportunity to demonstrate how important they are in the communities they serve. And though the process can seem daunting, it's your chance to tell your story while helping pave the way to a healthier tomorrow.

More resources

Still have questions?

If the COVID-19 reimbursement process still feels overwhelming, Good Neighbor Pharmacy can help. Get step-by-step instructions for vaccine implementation and updates on vaccine distribution.