CMS is increasing the payment rate Medicare will pay for administration of monoclonal antibodies (mAb) to treat beneficiaries with COVID-19, and Medicare Advantage plans should take note.
The national average payment rate has increased from $310 to $450 for most healthcare settings, and the agency also set a higher national payment rate of $750 for treatment administered in a beneficiary’s home. This applies to a beneficiary’s permanent residence, as well as hotels, cruise ships, homeless shelters and other temporary lodging.1
Administration of monoclonal antibody treatment soon after a COVID-19 diagnosis can reduce the risk of hospitalization or severe illness for beneficiaries at high risk.2 However, the antibodies are largely underutilized, as they must be given very soon after diagnosis and are only appropriate for a narrow population of high-risk patients with mild to moderate symptoms who are not hospitalized.3 In part because of these limitations, as of December 2020, only 5% to 20% of the available supply of mAb therapies for COVID-19 treatment had been used.3
The reimbursement rate increase, implemented based on feedback from stakeholders including the home health industry, better reflects the cost of clinical staff and personal protective equipment, according to CMS. It could improve beneficiary access to monoclonal antibody products.4,5
As of now, two investigational monoclonal antibody therapies are available under FDA emergency use authorization for mild to moderate COVID-19 in adults and pediatric patients with COVID-19 who are at high risk for severe COVID-19, hospitalization or both.6 These therapies are:
- Casirivimab and imdevimab, administered together
- Bamlanivimab and etesevimab, administered together
Reimbursement will be higher under the new policy, but if the change incentivizes greater use of mAb treatments, MA plans could see reduced hospitalizations, lower overall COVID-19 care costs and – most importantly – better COVID-19 outcomes.
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References
- CMS increases Medicare payment for COVID-19 monoclonal antibody infusions. CMS Newsroom. May 6, 2021. https://www.cms.gov/newsroom/press-releases/cms-increases-medicare-payment-covid-19-monoclonal-antibody-infusions
- COVID-19 resources for healthcare professionals. HHS. https://combatcovid.hhs.gov/hcp/resources
- Pezenik, S. Why are authorized monoclonal antibodies rarely being used to treat Covid-19? ABC News. Dec. 18, 2020. https://abcnews.go.com/Health/authorized-monoclonal-antibody-rarely-treat-covid-19/story?id=74787113
- Paavola, A. CMS boosts Medicare payments for COVID-19 antibody infusions. Becker’s Hospital CFO Report. May 6, 2021. https://www.beckershospitalreview.com/finance/cms-boosts-medicare-payments-for-covid-19-antibody-infusions.html
- LaPointe, J. Medicare payment bumped for COVID-19 antibody, at-home infusions. RevCycle Intelligence. May 7, 2021. https://revcycleintelligence.com/news/medicare-payment-bumped-for-covid-19-antibody-at-home-infusions
- Monoclonal antibody COVID-19 infusion. CMS. May 11, 2021. https://www.cms.gov/medicare/covid-19/monoclonal-antibody-covid-19-infusion
