SNF: Enforcement Discretion Relating to Certain Pharmacy Billing

For flu, pneumococcal, and COVID-19 vaccines furnished on or after July 1, 2023, to patients in a Medicare Part A-covered skilled nursing facility (SNF) stay, immunizers can no longer bill Medicare directly. Typical SNF consolidated billing regulations are in place, which require SNFs to bill for all services furnished to patients in a Medicare-covered SNF stay, including vaccines. Third-party suppliers furnishing these vaccines under arrangement with the SNF must seek payment from the SNF for their services. Immunizers may still bill Medicare directly for vaccines furnished before July 1, 2023. The SNF enforcement discretion described below ended on June 30, 2023.

SNF Enforcement Discretion Before July 1, 2023

Billing for COVID-19 Vaccines

During the COVID-19 PHE,outside immunizers helped fill the need to provide onsite vaccinations at SNFs. They were Medicare-enrolled vaccinators who could bill directly and get direct reimbursement from the Medicare program.

Sections 1862(a)(18) and 1842(b)(6)(E) of the Social Security Act require SNFs to bill for certain services, including vaccine administration, even when SNFs rely on an outside vendor to perform the service. But, to facilitate the efficient administration of COVID-19 vaccines to patients in a Part A-covered SNF stay, CMS exercised “enforcement discretion,” which allowed Medicare-enrolled immunizers, including but not limited to pharmacies working with the U.S., to bill directly and get direct payment from the Medicare program for vaccinating Medicare SNF residents.

Billing for Flu & Pneumococcal Vaccines

To help efficiently administer flu or pneumococcal vaccines to SNF residents during the COVID-19 PHE, CMS exercised enforcement discretion from September 20, 2021 – June 30, 2023, to allow Medicare-enrolled immunizers and SNFs to bill directly and get direct Medicare reimbursement for vaccinating SNF residents with the seasonal flu vaccine and pneumococcal vaccine (including for vaccine administration and product). Medicare-enrolled immunizers could bill and get reimbursed for these vaccines whether they administered them at the same time (co-administered) with a COVID-19 vaccine or if they were administered at different times.  

For example, if a SNF or Medicare-enrolled immunizer administered a flu vaccine and a COVID-19 vaccine shot to a Medicare patient between September 20, 2021, and June 30, 2023, they could bill Medicare (or Medicare Advantage plans, as appropriate) for the flu vaccine administration, flu vaccine product, and the COVID-19 vaccine shot administration.