Originally received via email from the Department of Health Care Services, Jan 14, 2021.
The Department of Health Care Services (DHCS) is seeking federal approval to help support delivery of the vaccine to all Medi-Cal beneficiaries. The vaccine will be provided at no cost to all Californians. The purpose of this Q&A is to provide information on who is covered, how to get vaccinated, and how DHCS plans to reimburse providers for the administration fee tied to the vaccine under Medi-Cal.
Who is covered to get vaccinated?
All full-scope Medi-Cal beneficiaries are covered and will receive the vaccine at no cost. Coverage is also extended to people enrolled in restricted-scope Medi-Cal; the COVID-19 Uninsured Group Program; and the Family Planning, Access, Care, and Treatment (FPACT) program.
Where and when are vaccinations being administered?
California’s plan for administering the vaccine is initially limited and split into phases. More details on those phases, including who is covered in each one, and on the vaccination roll-out in general are available on the vaccination section of the California for All COVID-19 website.
The California Department of Public Health is working with local agencies to distribute COVID-19 vaccines. Local health departments are identifying facilities that have the capacity to properly maintain the vaccine while meeting all federal and state requirements. Enrollment in the vaccine distribution program is limited at this time to providers authorized by their local health department. Others may enroll as vaccine supply increases.
Who do providers bill?
As the federal government will pay for the initial vaccines, there is no Medi-Cal provider reimbursement for the COVID-19 vaccine itself. Providers will bill for administration of the COVID-19 vaccine on medical, outpatient, or pharmacy claims. DHCS will reimburse providers the vaccine administration for all covered Medi-Cal populations exclusively through the Medi-Cal fee-for-service (FFS) delivery system. This includes administration to individuals enrolled in Medi-Cal managed-care health plans.
What is the reimbursement rate that DHCS will pay?
DHCS is seeking federal approval to pay all providers up to the Medicare rate for COVID vaccinations, subject to Medi-Cal FFS policy. The maximum allowable rate for a single-dose vaccine is $28.39; the maximum for a double-dose vaccine is $16.94 for the initial dose and $28.39 for the final dose ($45.33 total).
What about Federally Qualified Health Centers (FQHCs), Rural Health Clinics, (RHCs) and Tribal Clinics?
DHCS will pay the applicable Prospective Payment System (PPS)/All Inclusive Rate (AIR) if the vaccination is administered during an in-person visit that meets the requirements of a billable office visit in the clinic setting. If the vaccine administration does not meet all of the requirements of a billable visit (i.e. only vaccine administration), the FQHC, RHC, and Tribal Clinic can bill Medi-Cal FFS for administering the COVID vaccine and be reimbursed the applicable dosage rate as noted above.
There is more COVID-19 vaccine information on the DHCS website, including a Frequently Asked Questions document and a COVID-19 vaccine administration letter to Medi-Cal managed care plans. The California for All COVID-19 website also has information about local resources, including links to county COVID-19 websites.