SNF: Enforcement Discretion Relating to Certain Pharmacy Billing

The COVID-19 public health emergency (PHE) ended at the end of the day on May 11, 2023. View Infectious diseases for a list of waivers and flexibilities that were in place during the PHE.

Review this page for information about SNF enforcement discretion for administering COVID-19 vaccines during and after the PHE. The SNF enforcement discretion described on this page will end on June 30, 2023.

CMS appreciates its long-standing partnership with immunizers, including pharmacies, to facilitate the efficient administration of vaccines, particularly for vulnerable populations in long-term care facilities and other congregate care settings across America. Leveraging immunizers’ capabilities and expertise has played an important role in the Department’s ability to broadly distribute and administer COVID-19 vaccines, including to people with Medicare.

The COVID-19 PHE presented an unprecedented challenge. Quickly, safely, and effectively vaccinating our most vulnerable citizens in settings that have accounted for about 30 percent of U.S. COVID-19 deaths has been a top-priority. Unfortunately, during the PHE, many long-term care facilities may not have had sufficient capacity to get, store, and administer vaccines. And some long-term care facility residents couldn’t safely leave the facility to get vaccinations.

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

The Social Security Act requires SNFs to bill for certain services, including vaccine administration, even when SNFs rely on an outside vendor to perform the service. See Social Security Act §§ 1862(a)(18), 1842(b)(6)(E).

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.

CMS also recognized that vaccinations for respiratory illnesses, such as flu and pneumococcal vaccines, could help reduce the impact of these respiratory illnesses and the resulting burdens on the health care system during the COVID-19 PHE. To help efficiently administer flu or pneumococcal vaccines to SNF residents during the COVID-19 PHE, effective as of September 20, 2021, CMS exercised enforcement discretion to allow Medicare-enrolled immunizers to bill directly and get direct reimbursement from the Medicare program for vaccinating SNF residents with the seasonal flu vaccine and pneumococcal vaccine (including for vaccine administration and product) whether they administer these vaccines at the same time (co-administered) with a COVID-19 vaccine or if theyre administered at different times. We continue to expect immunizers to work with SNFs to appropriately address SNF residents’ vaccine-related clinical needs.  

Administration and products for these vaccines may all be billed to Medicare. For example, if a SNF administers a flu vaccine and a COVID-19 vaccine shot to a Medicare patient, they may bill Medicare (or Medicare Advantage plans, as appropriate) for the flu vaccine administration, flu vaccine product, and also the COVID-19 vaccine shot administration. Through the exercise of the discretion described above, CMS has also allowed Medicare-enrolled immunizers to bill in such a manner.

The enforcement discretion described above will end on June 30, 2023. This means immunizers will no longer be able to bill Medicare directly for vaccines furnished to patients for a Medicare Part A-covered SNF stay after June 30, 2023. Beginning on July 1, typical SNF consolidated billing regulations will be in place, which require SNFs to bill for all services furnished to patients in a Medicare-covered SNF stay, including vaccines.



Page Last Modified:
05/12/2023 12:31 PM