HOME
ABOUT IAC
CONTACT
A-Z INDEX
DONATE
SHOP
SUBSCRIBE
Immunize.org logo formerly Immunization Action Coalition (IAC)
IAC Home
|
Ask the Experts
|
Billing and Reimbursement

Ask the Experts

Billing and Reimbursement

Make a Donation Ask the Experts Home
Administering Vaccines
Billing and Reimbursement
Combination Vaccines
Contraindications and Precautions
COVID-19
Dengue
Diphtheria
Documenting Vaccination
Hib
Hepatitis A
Hepatitis B
HPV
Influenza
MMR
Meningococcal ACWY
Meningococcal B
Pertussis
Pneumococcal
Polio
Rabies
Rotavirus
Scheduling Vaccines
Storage and Handling
Tetanus
Travel Vaccines
Vaccine Recommendations
Vaccine Safety
Varicella (chickenpox)
Zoster (shingles)
 
Billing and Reimbursement
What is the Vaccines for Children (VFC) program and who is eligible?
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 one or more vaccines included in VFC, or whose insurance plan has a fixed dollar cap for vaccines (after the cap is reached) are considered "underinsured" and 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.
A child is covered by health insurance which covers all routine childhood vaccines, but the parent has not met the deductible for the year, is the child eligible for VFC vaccine?
Most commercial insurance plans provide coverage of routine vaccinations with no out-of-pocket cost to the family. However, a child whose health insurance plan covers the cost of vaccinations as a benefit is not eligible for VFC vaccines, even if the plan requires a copay or requires that they meet a deductible for the year.
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 (PCV20, Prevnar 20, Pfizer, or PCV15, Vaxneuvance, Merck), and hepatitis B (for patients at high or intermediate risk). Medicare Part B does not cover other adult 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 (ACIP). Payment for Part D-covered vaccines and their administration is currently determined solely by the patient's prescription drug plan. The Inflation Reduction Act of 2022 will require Medicare Part D plans to begin covering ACIP-recommended adult vaccinations without a deductible or copay beginning later in 2023.
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 Immunize.org 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.
The Inflation Reduction Act of 2022, once fully enacted during 2023, will substantially reduce cost-related barriers to vaccination for adults. The law eliminates cost-sharing for ACIP-recommended vaccination of all adults covered by Medicaid and Medicaid expansion plans, as well as adults with Medicare Part D. It also provides for enhanced federal reimbursement for immunizing providers. Details about implementation are forthcoming at the time of this update.
Back to top
This page was updated on August 26, 2022.
This page was reviewed on August 26, 2022.
 
- Guide to immunize.org -
A-Z INDEX
ABOUT IAC
IAC in the News
Staff
IAC History through Film
ACIP
RECOMMENDATIONS
ADOLESCENT VACCINATION
ADULT VACCINATION
ADULT VACCINATION GUIDE
ASK THE EXPERTS
Administering Vaccines
COVID-19
Hepatitis B
MMR
Storage and Handling
>> view all
BECKY PAYNE AWARD
BILLING & CODING
BIRTH DOSE GUIDEBOOK
CALENDAR OF EVENTS
CDC INFORMATION
CDC SCHEDULES
CLINIC TOOLS
Administering Vaccines
Adolescent Vaccination
Adult Vaccination
Screening for Contraindications
Storage & Handling
Vaccine Recommendations
>> view all
COALITIONS FOR
IMMUNIZATION
CONTRIBUTE TO IAC
COVID-19 RELATED
Ask the Experts: COVID-19
Vaccines: COVID-19
DEAR COLLEAGUE LETTERS
16-year-old Visit
HPV
MenACWY Dose #2
DONATE TO IAC
EDUCATIONAL MATERIALS
EMAIL NEWS SERVICES
E-NEWSLETTER: IZ EXPRESS
EXEMPTIONS
FAQs
FAVORITES
FDA PACKAGE INSERTS
FILMS ABOUT IAC
GIVE BIRTH TO THE
END OF HEP B
HANDOUTS FOR
PATIENTS & STAFF
View All Materials
Administering Vaccines
Adolescent Vaccination
Adult Vaccination
Contraindications / Precautions
Documenting Vaccination
Healthcare Personnel
Managing Vaccine Reactions
Parent Handouts
Pregnancy and Vaccines
Q&As: Diseases and Vaccines
Schedules for Patients
Screening Checklists
Standing Orders Templates
Storage & Handling
Strategies & Policies
Temperature Logs
Top Handouts
Vaccine Confidence
Vaccine Recommendations
>> view all
HEP B BIRTH DOSE
HONOR ROLLS
Hep B Birth Dose
Mandatory Flu Vaccination for HCP
MenB Vaccination for Colleges
IZ EXPRESS
Subscribe to IZ Express
IMAGE LIBRARY
LAWS AND MANDATES
MANUFACTURERS
MASS VACCINATION
RESOURCES
NATIONAL ADULT &
INFLUENZA
IMMUNIZATION SUMMIT
NEWS & INFORMATION
NEWSLETTER SIGN UP
OFFICIAL RELEASES
ACIP
CDC
FDA
PACKAGE INSERTS
PARTNERS
PHARMACISTS
PHOTOS
PREGNANCY AND
VACCINES
PRESS ROOM
PROTECT NEWBORNS
FROM HEP B
PUBLICATIONS
IZ Express
Vaccinating Adults:
   A Step-by-Step Guide
Hepatitis B What Hospitals
   Need to Do to
   Protect Newborns
Needle Tips Archive
Vaccinate Adults Archive
Vaccinate Women Archive
REGISTRIES
SCHOOL VACCINATION REQUIREMENTS
SHOP IAC
DVD Immunization Techniques
Laminated Schedules
Patient Record Cards
Flu Vaccine Buttons and Stickers
"Vaccines Save Lives" Pins
SITE MAP
STANDING ORDERS
STATE INFORMATION
Immunization Websites
Laws and Mandates for School Entry
Immunization Program Managers
SUBSCRIBE TO IZ EXPRESS
SUPPORT IAC
TALKING ABOUT VACCINES
Adjuvants & Ingredients
Autism
Importance of Vaccination
MMR Vaccine
Religious Concerns
Vaccine Safety
>> view all
TECHNICALLY SPEAKING
(ARCHIVE)
TRANSLATIONS
IAC Handouts
VISs
TRAVEL (INTERNATIONAL)
UNPROTECTED PEOPLE
STORIES
Chickenpox
Hepatitis B
Measles
Whooping Cough
>> view all
VACCINATING ADULTS:
A STEP-BY-STEP GUIDE
VACCINE INFORMATION
STATEMENTS
Translations
VACCINE
MANUFACTURERS
VACCINE POLICY &
LICENSURE
ACIP
FDA
WHO
VACCINE SAFETY
VACCINE TIMELINE
VACCINES
COVID-19
Hepatitis B
HPV (Human papillomavirus)
Influenza
Monkeypox (mpox)
Pertussis
Varicella
>> view all
VIDEO OF THE WEEK
VIDEO LIBRARY
VISs
Translations
WHAT'S NEW OR UPDATED AT IAC
Handouts
VISs and Translations
Web Pages
 
Immunize.org  •  2136 Ford Parkway  •  Suite 5011  •  Saint Paul, Minnesota  •  55116
tel 651-647-9009  •  fax 651-647-9131
 
 
 
This website is supported in part by a cooperative agreement from the National Center for Immunization and Respiratory Diseases (Grant No. 1NH23IP922654) 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.