CMS Finalizes Additional Payment for New COVID-19 Treatments

Payment for New COVID-19 Treatments

CMS’ Fourth COVID-19 Interim Final Rule with Comment Period (IFC-4) includes additional payment for new COVID-19 treatments, price transparency requirements for COVID-19 diagnostic tests, and coverage for potential vaccines among other provisions. Most provisions of IFC-4 became effective November 2.

Hospital Payment for New COVID-19 Treatments

The New COVID-19 Treatments Add-on Payment (NCTAP) will provide additional Medicare payment for eligible hospital inpatient and outpatient cases that involve certain new products or treatments authorized or approved for COVID-19 for the duration of the public health emergency.

For hospital inpatient discharges occurring on or after November 2, the enhanced payment is the lesser of:

  • 65% of the operating outlier threshold for the claim
  • 65% of the cost of a COVID-19 stay beyond the operating Medicare payment, including the 20% add-on payment under section 3710 of the CARES Act

The NCTAP will not be included in the operating outlier payment calculation.

For hospital outpatient encounters, Medicare will pay separately for drugs and biologicals authorized or approved by the FDA to treat COVID-19 when billed on the same claim as a primary C-APC service. Although CMS expects such situations to be rare, it opted to exclude these treatments from being packaged in C-APC payments to avoid discouraging their use.

Price Transparency

Any facility that performs one or more type of COVID-19 diagnostic test, including molecular, antigen, and serological tests, must publicize the cash price. IFC-4 defines the cash price as the “charge that applies to an individual who pays in cash (or cash equivalent) for a COVID-19 diagnostic test.” Similar to CMS’ other price transparency requirements, the cash price must be published on the facility’s website in a conspicuous location. If a facility does not have a website, it must prominently post the cash price information on signage at the location testing is performed.

Coding and Billing Processes For Potential Vaccines

CMS will add any potential COVID-19 vaccines to the list of preventive vaccines that are covered under Medicare Part B without coinsurance or deductible. IFC-4 also requires non-grandfathered private health plans to cover COVID-19 vaccines without beneficiary cost sharing.

CMS anticipates that specific codes, coding guidelines, and billing rules will be published as vaccines become available. The agency will forego the rulemaking process and will establish interim payment rates and APC assignments.

CMS expects to base billing processes on those already in place for influenza vaccines.

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