| Billing and Reimbursement |
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| What is the Vaccines for Children (VFC) program and who is eligible? |
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| 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). |
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| 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. |
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| If a child isn't covered by health insurance but the parent plans to get insurance, is the child eligible for VFC vaccine? |
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| 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. |
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| 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? |
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| 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. |
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| Do I need to verify my patient's residency status before using VFC vaccine? |
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| 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. |
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| What vaccines are covered by Medicare? |
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| 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. |
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| 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. |
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| I want to begin providing vaccines for my adult patients but reimbursement for these vaccines is confusing. Can you provide guidance? |
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| 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. |
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| 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. |
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ACIP Recommendations
Vaccine Information Statements 
