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Billing and Reimbursement

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Billing and Reimbursement

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Billing and Reimbursement
What is the Vaccines for Children (VFC) program?
VFC is a program designed to reduce or eliminate vaccine cost as a barrier to childhood vaccination. The program purchases vaccines from manufacturers at federal contract prices and provides them at no cost to participating public and private healthcare providers for use in children through age 18 years who are eligible for Medicaid, are uninsured, or are American Indian or Native American. Children whose health insurance benefit plan does not cover a particular VFC vaccine are also able to receive VFC vaccine at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). If you are interested in becoming a VFC provider, you should contact your state immunization program. For more information on the VFC program in general, go to the CDC's website at www.cdc.gov/vaccines/programs/vfc/index.html.
If a child isn't covered by health insurance but the parent plans to get insurance, is the child eligible for VFC vaccine?
If the child has no health insurance on the day he or she presents at a medical practice or health department for immunization, the child is VFC eligible because he or she is uninsured. A child must be screened for VFC eligibility at each visit, even though the eligibility form needs to be updated only when the child's eligibility status changes.
Do I need to verify my patient's residency status before using VFC vaccine?
No. The CDC states that the only criteria are age (age 18 years or younger) and the four eligibility criteria listed previously. No other factors (for example, residency status) can be considered when screening for eligibility requirements for the VFC program.
What vaccines are covered by Medicare?
Medicare Part B (medical insurance) statutorily covers four recommended vaccines for Medicare beneficiaries: influenza, pneumococcal polysaccharide (Pneumovax 23, Merck), pneumococcal conjugate (Prevnar 13, Pfizer), and hepatitis B (for patients at high or intermediate risk). Medicare Part B does not cover other vaccinations (e.g., Tdap and zoster) unless they are directly related to the treatment of an injury or direct exposure to a disease, such as anti-rabies treatment or tetanus prevention due to an injury. In the absence of injury or direct exposure, preventive immunization against diseases such as tetanus, pertussis, or diphtheria is not covered by Part B.
Medicare Part D plans (outpatient prescription drug insurance) generally cover vaccines that Part B does not cover (for example Tdap and zoster), as long as the vaccine is recommended by the Advisory Committee on Immunization Practices. Payment for Part D-covered vaccines and their administration is determined solely by the patientís prescription drug plan.
I want to begin providing vaccines for my adult patients but reimbursement for these vaccines is confusing. Can you provide guidance?
In 2017, the Immunization Action Coalition revised its comprehensive142-page guide titled Vaccinating Adults: A Step-by-Step Guide. The guide was written to assist medical practices to improve their adult vaccination services. Two of the chapters (7A and 7B) address financial considerations and provide guidance on how to obtain reimbursement for adult vaccines. The guide is available free of charge on the IAC website at www.immunize.org/guide. In addition, the National Adult and Influenza Immunization Summit has created a web section on this topic at www.izsummitpartners.org/naiis-workgroups/access-provider-workgroup/coding-and-billing.
This page was updated on July 25, 2018.
This page was reviewed on February 14, 2018.
 
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This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 6NH23IP22550) at the Centers for Disease Control and Prevention (CDC) in Atlanta, GA. The website content is the sole responsibility of IAC and does not necessarily represent the official views of CDC.