COVID-19 Vaccine Administration Rate Change Effective April 1

Published on
April 5, 2021

On March 15, 2021, the Centers for Medicare and Medicaid Services (CMS) released an updated version of the Coverage and Reimbursement of COVID-19 Vaccines, Vaccine Administration, and Cost-Sharing under Medicaid, the Children's Health Insurance Program, and Basic Health Program Toolkit. The Medicare administration rate is changed to $40 per vaccine administration.

Beginning April 1, 2021, HHSC set the fee-for-service (FFS) reimbursement rates to align with Medicare. For all COVID-19 vaccines, the FFS administration reimbursement rate is $40 for each administration. If a person receives a multi-dose vaccine, then Medicaid should reimburse providers $40 for each dose's administration.

Pharmacies must continue to follow the claim submission guidance. Pharmacies submitting claims for the initial dose of a COVID vaccine must use the value "02" (Other Override) in the "Submission Clarification Code" field (42Ø-DK) to indicate the first dose of a multi-dose vaccine. Pharmacies must submit the final dose with a value of "06" (Starter Dose) in field 42Ø-DK. For single-dose vaccines, pharmacies must submit a value of "06" (Starter Dose) in field 42Ø-DK.