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The purpose of this bulletin is to inform providers that DMAS fee-for-service (FFS) and all contracted managed care plans will ensure coverage of: 1) the following COVID-19 antibody product, and 2) COVID-19 vaccine administration in the home as outlined below.

For further information on COVID-19 monoclonal antibody product and vaccine administration coverage, please review previous DMAS memos here: https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/MedicaidMemostoProviders.

COVID-19 Antibody Product

DMAS FFS and all managed care plans will ensure coverage of the following COVID-19 antibody product code with claims from dates of service on or after the dates listed below and when Requirements for Reimbursement of Antibody Products are met in accordance with Section 6008(b)(4) of the Families First Coronavirus Response Act. Current FFS reimbursement rates for the codes described below are available for reference via the DMAS fee file. Managed Care Organizations (MCOs) can be reached at the contacts listed at the end of this memo for MCO-specific reimbursement rates.

• Q0244* (6/3/2021): Injection, casirivimab and imdevimab, 1200 mg

*The Centers for Medicare and Medicaid Services (CMS) anticipates that, at this time, providers will not incur a cost for COVID-19 monoclonal antibody products. Providers should not bill for a COVID-19 monoclonal antibody product if they received it for free.

An M0243 administration billing code may be appropriate to submit in conjunction with the COVID-19 antibody prophylaxis code covered above, when the requirements for reimbursement, and conditions associated with M0243, are met.

Requirements for Reimbursement of Antibody Products

DMAS FFS and all managed care plans will reimburse providers for the COVID-19 antibody product code outlined above under the following conditions:

• Treatment has an FDA Emergency Use Authorization (EUA) or FDA approval at the time the treatment is administered, AND
• Patient meets the criteria identified in the EUA Limitations of Authorized Use or FDA approval letter

These conditions include use of the above code for both treatment and prophylaxis indications outlined in the amended FDA EUA for casirivimab and imdevimab.

Claims submitted on or after the coverage dates listed above which were initially denied on the grounds of non-coverage will be reprocessed by DMAS FFS and all managed care plans without requiring resubmission of claims.

COVID-19 Vaccine Administration in the Home

DMAS FFS and all managed care plans will ensure coverage of the following COVID-19 vaccine home administration add-on code with claims from dates of service on or after the dates listed below and when Requirements for Reimbursement of COVID-19 Vaccine Administration in the Home are met. This is in accordance with the 2021 Appropriations Act, Item 313.UUUUU, authorizing DMAS to set the administration fee for COVID-19 vaccines at the same level as Medicare reimbursement for such vaccines. Current FFS reimbursement rates for the codes described below are available for reference via the DMAS fee file. Use the contact information listed at the end of this memo to request Managed Care-specific reimbursement rates from the Managed Care Organizations (MCOs).

• M0201 (6/8/21): Covid-19 vaccine administration inside a patient's home; reported only once per individual home per date of service when only Covid-19 vaccine administration is performed at the patient's home

M0201 may be billed in addition to the applicable COVID-19 administration code for the vaccine product administered. For multiple-dose vaccines and booster doses, M0201 may be billed for each COVID-19 vaccine dose covered by DMAS , and administered in an appropriate setting, as outlined below, consistent with Medicare payment for COVID-19 vaccine administration in the home.

Requirements for Reimbursement of COVID-19 Vaccine Administration in the Home

To receive payment for this code for vaccine administration in the home, all of the following must be met:

• Patients must have difficulties leaving their homes or be hard to reach, as demonstrated by at least one of the following:
  • The patient has a condition that makes them more susceptible to contracting a pandemic disease such as COVID-19
  • The patient is generally unable to leave the home, and if they do leave home it requires a considerable and taxing effort
  • The patient has a disability or faces clinical, socioeconomic, or geographical barriers to getting a COVID-19 vaccine in settings other than their home
  • The patient faces challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving
• Vaccine administration must be performed in one of the following qualifying locations:
  • Private residence
  • Temporary lodging (e.g., hotel/motel, campground, hostel, or homeless shelter)
  • Apartment within an apartment complex
  • Unit in an assisted living facility or group home (albeit NOT in a nursing facility or Medicaid supportive living program (SLP))
  • Effective August 24, 2021, communal spaces of a multi-unit or communal living arrangement
  • Effective August 24, 2021, assisted living facilities participating in the CDC’s Pharmacy Partnership for Long-Term Care Program when their residents are vaccinated through this program
• The sole purpose of the visit is to administer a COVID-19 vaccine. M0201 is not billable if another covered service is provided in the same home on the same date

Hospitals, skilled nursing facilities (SNFs) and Medicaid nursing facilities, are not eligible for M0201 regardless of whether they are the patient’s permanent residence.

M0201 is payable up to a maximum of 5 vaccine administration services per date of service, per home unit or communal space within a single group living location; but only when fewer than 10 Medicaid members receive a COVID-19 vaccine dose on the same day at the same group living location. When ten (10) or more Medicaid members receive a COVID-19 vaccine dose at a group living location on the same day, M0201 can only be billed once per home (whether the home is an individual living unit or a communal space).

Providers are not obligated to certify that members are homebound, but must document in the patient’s medical record their clinical status or the barriers they face to getting the vaccine outside the home.

For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed below.

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