December 17, 2020, 4:47 pm News Staff — Vaccinating Americans against COVID-19 while the pandemic continues to surge will be the most demanding and complex public health undertaking in the country’s history, and AAFP members remain at the leading edge of the work.
Behind the lines, the Academy is also working to make sure that the daunting financial and administrative challenges accompanying this critical push don’t further imperil family physician practices already under the wheels of a public health emergency stretching into an 11th month.
Specifically, the AAFP this week delivered extensive, sometimes forceful comments to federal regulators on a wide-ranging interim final rule on coverage and payment requirements for COVID-19 vaccines, including Medicaid provisions. The Academy advocated for coverage of COVID-19 vaccines without cost-sharing and sharply objected to elements of the rule that could result in loss of benefits, allow prior authorization requirements or increase cost-sharing for Medicaid beneficiaries.
“We are deeply concerned about the inequitable impact of COVID-19 and the significant financial strain that family medicine practices are facing,” said the Academy’s Dec. 16 letter.
“CMS must value the CPT codes for COVID-19 vaccine administration in such a way that the relative value reflects the additional practice expenses associated with administration of the corresponding COVID-19 vaccines.”
The 16-page letter was sent to HHS Secretary Alex Azar, Treasury Secretary Steven Mnuchin and Labor Secretary Eugene Scalia, J.D., in response to “Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” published Nov. 6 in the Federal Register. It was signed by Board Chair Gary LeRoy, M.D., of Dayton, Ohio.
Key subjects of the AAFP’s comments included the following.
The rule sets the Medicare payment rates for COVID-19 vaccine administration at $16.94 for the first of two doses and $28.39 for the last, subject to geographical adjustment.
Citing concerns with the inadequacy of current Medicare rates and the agency’s decision to set the Medicare rates for COVID-19 vaccine administration at a level comparable to that of administration of other Medicare Part B-covered vaccines, the Academy called on regulators to
“It is likely that current Medicare rates for vaccine administration will not sufficiently account for the resources required to stock, store and administer a new COVID-19 vaccine,” the letter said. “We strongly recommend that the value of the unique CPT codes for COVID-19 vaccine administration reflect these additional costs.”
Additionally, the AAFP recommended that CMS “encourage state Medicaid agencies to adopt payment rates that are at least equal to Medicare payment rates for COVID-19 vaccine administration.
The Academy voiced support for the rule’s plan to cover vaccine administration, without cost-sharing, to traditional Medicare and Medicare Advantage beneficiaries. The letter likewise supported CMS’ instruction that most private insurers cover COVID-19 vaccine administration without cost-sharing, regardless of whether the patient receives the vaccine from an in-network clinician.
The rule interprets the Families First Coronavirus Response Act (H.R.6201) as compelling states that accept increased federal financial support to cover COVID-19 vaccine administration without cost-sharing for most Medicaid beneficiaries during the public health emergency and through the end of the quarter in which the PHE ends.
The Academy disagreed, though, with the agency’s interpretation of H.R. 6201 as allowing states to apply cost-sharing to COVID-19 vaccine coverage for beneficiaries affected by Section 1115 waivers.
“Congress clearly intended all Medicaid enrollees, including those covered by a Section 1115 demonstration, to receive coverage for COVID-19 testing, treatment and vaccinations,” the letters said. “The Academy strongly recommends that CMS issue a final rule correcting this interpretation and providing that states must cover COVID-19 testing, therapeutics and vaccination without cost-sharing for all Medicaid enrollees during the PHE, regardless of their benefit category and including those covered under an existing 1115 demonstration. None of these enrollees should be considered uninsured for the purposes of vaccine coverage and reimbursement.
The AAFP objected to the rule’s interpretation of states’ maintenance of eligibility requirements determining receipt of a 6.2% increase in federal matching funds under the Families First Coronavirus Response Act. This new reading of the law represents a reversal from previous guidance, which required states to maintain enrollees’ benefit packages for the duration of the PHE.
“We also are opposed to the new provisions allowing states to eliminate optional benefits, and reduce the amount, duration and scope of covered benefits,” the letter said. “We are deeply concerned that this approach will create confusion and administrative burden for family physicians, as well as jeopardize the health of their patients enrolled in state Medicaid plans. The AAFP strongly urges CMS to abandon the alternative interpretation finalized in the interim final rule and instead reinstate the guidance on MOE requirements that was provided to states earlier this year.
“The AAFP has repeatedly encouraged Congress to increase the federal match for states for the duration of the PHE, and we continue to believe this is the best way to support states as they grapple with budget shortfalls and growing Medicaid rolls.”
The rule requires that practices post to their websites all pricing information for COVID-19 testing and seeks comments on appropriate penalties for those that do not comply. The Academy, while supportive of efforts to improve price transparency for patients, advised HHS to minimize any administrative or financial burdens that this requirement would introduce.
“To alleviate the burden associated with complying with this requirement, the AAFP believes providers of a COVID-19 diagnostic test should have the flexibility to display the information in a way that is most appropriate for their patient population,” the letter said.
The proposed rule would use patient reporting to determine whether a practice is in compliance, then potentially fine physicians after just one notice — approaches the AAFP took issue with.
“Relying on complaints to determine a provider’s potential noncompliance could result in incorrect reports of noncompliance,” the letter cautioned. “A provider may have the information available on their website but patients may inadvertently miss the information,” leading to an incorrect report.
Any monetary penalty, the Academy added, would “further threaten practices that are already struggling financially.”
“The dollar amount of these fines per day would devastate a small family practice and possibly force it to close. In order to avoid the possibility of incurring a civil monetary penalty, it is likely that some practices will instead stop offering COVID-19 tests.”