Coronavirus Disease 2019 (COVID-19) Vaccination Administration Coverage

The South Carolina Department of Health and Human Services (SCDHHS) will reimburse for COVID-19 vaccine administration, without patient cost-sharing, when provided to Healthy Connections Medicaid members in a manner consistent with recommendations of the Advisory Committee on Immunization Practices (ACIP). The information contained in this bulletin is intended to provide guidance on vaccine administration coverage during the initial period of availability when the vaccine is being federally purchased. SCDHHS will provide additional information as the approach to vaccine and vaccine administration financing changes.

For Medicaid members enrolled in a managed care organization (MCO), providers should bill the appropriate MCO for COVID-19 vaccine administration. Claims for fee-for-service (FFS) Medicaid members should be submitted to SCDHHS in the customary fashion. The initial phase of vaccine distribution is outside of the Vaccines for Children (VFC) program, so providers do not need to be enrolled in the VFC program to administer a COVID-19 vaccine to children enrolled in Healthy Connections Medicaid.

Since providers will not incur a cost for the vaccine itself, providers will only be reimbursed for the administration of the vaccine. The following guidelines apply to both FFS members and those enrolled in an MCO.

Professional Service Providers

Providers who generally submit claims using the CMS-1500 or 837P claim type will submit claims for COVID-19 vaccine administration using the appropriate current procedural terminology (CPT) code.

SCDHHS will adopt the billing codes, reimbursement rates and effective dates published by the Centers for Medicare and Medicaid Services (CMS) for Medicare Part B coverage, which are available on CMS’ website. The current administration codes are included in the table below. Please note, these codes are subject to change without notice. SCDHHS will maintain an updated list of vaccine and vaccine administration codes at www.scdhhs.gov/covid19.

SCDHHS will reimburse COVID-19 vaccine administration as a “bill-above” service for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs).

Pharmacy Providers

SCDHHS will reimburse pharmacy providers for administering COVID-19 vaccines through the pharmacy benefit, as detailed in the National Council for Prescription Drug Programs (NCPDP) Emergency Preparedness Guidance- COVID-19 Vaccines publication. SCDHHS will reimburse pharmacy providers at the Medicare Part B reimbursement rate for COVID-19 vaccine administration. Additional billing specifications will be provided.

Coverage for Medicare-Medicaid Members

For members enrolled in both the Medicare and the Healthy Connections Medicaid programs, including members of Healthy Connections Prime or Medicare Advantage plans, COVID-19 vaccine administration is provided through the Medicare Part B benefit. Additional information applicable to these members is available from CMS.

Coverage for Limited Benefit Members

SCDHHS will provide coverage for COVID-19 vaccine administration for members enrolled in the family planning and COVID-19 testing limited benefit programs. Those without another form of healthcare coverage can apply for SCDHHS’ COVID-19 Limited Benefit Program, which will cover the cost of a COVID-19 test and the administration of a COVID-19 vaccine when rendered by a Healthy Connections Medicaid-enrolled provider. Those interested in applying for this limited benefit program can visit http://apply.scdhhs.gov/ to learn more or apply online here.

The provider billing guidelines described above also apply to claims submitted for these members.

Effective and Claims Submission Dates

SCDHHS will reimburse for dates of service based on the effective dates for vaccine administration established by CMS. SCDHHS is actively instituting the billing standards recently adopted by CMS and NCPDP and will begin accepting claims for the services described in this bulletin no later than March 1, 2021.

Additional guidance regarding coverage policy will be communicated in future bulletins as needed. Providers are encouraged to view the resources, including responses to frequently asked questions, available at www.scdhhs.gov/covid19 and submit questions about COVID-19-related policy changes to covid@scdhhs.gov.

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.

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