COVID-19 Vaccination Monitoring: COVAX and Considerations For Part D

The Centers for Medicaid and Medicare Services (CMS) plays an important role in facilitating access to COVID-19 vaccinations for Medicare recipients, protecting America’s senior citizens from COVID-19.  

Medicare Part D plans have an obligation to perform health care operations such as case management, care coordination or population-based activities to improve the health of their Medicare enrollees. For Part D plans to manage COVID-19 vaccine access and completion, those plans need to know when their enrolled Medicare members are receiving vaccinations.

CMS issued a bulletin titled “Access to COVID-19 Vaccine Data for Parts C & D Enrollees” on January 7, 2021, outlining methods for Part D plans to access information on Medicare members’ COVID-19 vaccine administration, which CMS refers to as COVAX.

This memo confirms that CMS “will process all claims for payment for COVID-19 vaccine for COVAX administration for the vast majority of Medicare beneficiaries through the original fee-for-service Medicare program.” The memo goes on to state that while Part D plans will not be making payments for vaccine administration through 2021, “CMS encourages these plans to help ensure their enrollees receive an initial COVAX dose when available to them, as well as any second dose per clinical recommendations.”

The CMS payment model for Medicare COVID-19 vaccinations creates a challenge for Part D plans:  they must perform patient care management, but are missing critical pieces of information such as who is getting vaccinated, where and when.

Pharmacies are submitting COVID-19 vaccine claims, as instructed, to the fee-for-service Medicare processors. This puts this activity outside of the “business as usual” pharmacy claim process and leaves Part D plans without visibility to information they need to meet their obligations.      

As a solution, CMS is offering Part D plans the option of obtaining COVAX information from a web portal or with real-time D.0 Point of Service (POS) COVAX transactions from the CMS TrOOP Facilitator to the Part D plan’s claims processor. The POS solution would make near-real-time COVAX information available to the Part D plans. 

As Part D plans are making decisions on how to handle COVAX information, there are many factors that must be considered, including the three areas of impact below.

1. How will the COVAX information-only transactions be presented to Part D plans by their processors?  To ensure that care management systems accurately reflect members’ COVAX status, Part D plans opting to receive the POS COVAX transactions should work closely with their processors to understand how these will be uniquely identified, including back-outs (reversals) of previously reported COVAX transactions. Plans should be able to include entries and later remove records from their care management system if needed.
2. How can plans ensure pharmacies are not impacted financially by COVAX transactions? Pharmacies are not submitting Part D COVID-19 vaccination claims to pharmacy claims processors for payment, so COVAX information-only transactions should not have a financial impact on pharmacies. These transactions should be excluded from host processing fees or other fees that may normally be assessed to pharmacies on POS transactions. The COVAX transactions should also be excluded from pharmacy remittance advice reporting of prescription drug payments.
3. How are Part D reporting and member communication impacted by COVAX transactions? COVAX transactions provide information to Part D plans and are not processed as prescription drug claims. COVAX transactions should be excluded from Prescription Drug Event (PDE) reporting, member Part D Explanation of Benefits (EOB) and other reports of prescription drug outcomes because they are informational and not submitted for adjudication. 

POS COVAX transactions are intended to provide Part D plans with the information they need to manage Medicare members through the critical COVID-19 vaccination process, but the solution can be complicated because it’s outside the normal pharmacy claim adjudication methods. This solution also had a very short implementation timeframe, with initial CMS notification released on January 7, 2021, and the receipt of the POS COVAX available as early as mid-March, 2021.

SS&C Health offers COVAX processing logic, which gives Part D plans the critical COVID-19 vaccine administration details required to meet CMS obligation and provide the best care for their Medicare members. Contact us for more information on SS&C’s support of Medicare Part D plans.