​The COVID-19 public health emergency ended in May 2023, bringing a broad array of changes to the way skilled nursing facilities will manage COVID-19 care. One of the most important developments is that as of July 1, 2023, a provider’s consultant pharmacy will no longer be able to bill Medicare for the administration fees associated with COVID-19 vaccines given to patients receiving Medicare Part A coverage. Instead, that responsibility will fall back to providers.

“Under Medicare, they waived the consolidated billing rule for vaccinations,” explained TJ Griffin, chief pharmacy officer at PharMerica. “Because it was free, the pharmacies could bill for the administration fee without any problem in a skilled nursing setting for those Medicare A patients. On July 1, all of that reverts back to the consolidated billing process that existed before.”

This change applies to Medicare Part A patients, whose vaccinations are covered under Medicare Part B. For custodial patients receiving Medicare Part D coverage, however, pharmacies will still be able to handle the billing process.

New Data Reporting Requirements

As with everything else in health care, providers’ new responsibility will be far from straightforward. For every vaccine administered throughout the pandemic, a record is filed with authorities tracking immunizations. The CDC no longer collects this data, but 63 state and city authorities still do. During the public health emergency, pharmacies that administered vaccines to nursing home patients not only took care of billing, but also managed data collection and reporting. Effective July 1, this responsibility—for Part A residents—will revert to providers.

This change poses a considerable challenge for providers already stretched thin by care and administrative demands. As Griffin explained, facilities generally don’t have the mechanisms to report vaccine administration to various regional immunization information systems (IIS), and the broader IIS infrastructure doesn’t have the capacity to handle a sudden wave of input from providers across the country.

“None of the eMAR systems have integrated with those immunization information systems," Griffin said. "There's not one system, there's 63. A facility in theory could also sign up with those IIS, but they don't have the staff or the wherewithal to do that. And frankly, it would probably blow up the whole IIS information structure if 14,000 skilled nursing facilities across the United States tried to sign up to their system, because they can't handle it.”

In practice, Griffin expects that facilities will continue partnering with pharmacies for vaccine reporting, given their existing reporting mechanisms and the institutional knowledge they bring to the table.

What Else Do Providers Need to Know?

Beyond July 1, providers should be aware of a few other immunization policy changes on the horizon. The vaccine itself will remain free until the federal stockpile depletes, which Griffin anticipates will happen in August or September. At that point, federal distribution will give way to commercial distribution, with vaccines expected to cost $130/dose. Most private insurance providers will cover these commercialized vaccines as preventive care; they will also still be covered under Medicare Part B and Medicare Advantage without cost-sharing, as they are now.

“When a facility submits for that, they'll get reimbursed for the product and then they'll get that administration fee," Griffin said of the commercialized vaccines. Some coordination with pharmacy partners will still be necessary when it comes to reporting requirements. The commercialized vaccines will also be delivered in single-dose vials rather than the multi-dose vials currently in use. "That's good news, which will make it easier for the pharmacy and for the facility," he said. "If they only have six patients, the pharmacy will send them six doses.”

The federal stockpile of oral therapies for COVID-19 remains robust, with enough to last until or through the fourth quarter of 2023. At that point, a transition to commercial distribution will take place, and oral therapies may involve cost-sharing or co-pays for patients on private insurers and Medicare.

Griffin noted that the FDA approved Paxlovid last month, so commercial billing has already begun for Medicare Part D members receiving that medication. "If you have a Medicare Part A patient, that would be part of the consolidated billing," he added. "It'd be like any other drug that's sent to them once the free supply is out. And that's going to run about $800 for a course of therapy.”

Seth SimonsWhat can providers do to prepare for these changes? Simple: start coordinating with their pharmacy partners sooner rather than later.

“I would start now, in June, working with your pharmacy," Griffin advised. "'Ask: what is going to change for us on July 1? Are we a mandatory reporting state? What's the plan on July 1 for how this is going to continue?’” 

Additional information is also available via HHS.

Steve Manning is a journalist based in New York City.