Understanding Vaccine Billing Changes for 2008

MARCH 01, 2008
April S. Brown, PharmD, RPh

Dr. Brown works in Corporate Development for Sweetbay Clinical Programs & Initiatives in southwest Florida.

Pharmacists should be aware of important changes in 2008 to the Centers for Medicare & Medicaid Services (CMS) policy for the reimbursement of Part D vaccine administration fees. Many pharmacists and other practitioners are erroneously interpreting announcements about these billing changes to mean that all vaccine reimbursements are shifting from Medicare Part B to Part D.

Pharmacists planning for flu clinics or those planning to incorporate pneumococcal vaccinations into work flow (based on an incorrect assumption that these vaccines will be covered under Part D beginning in 2008) will experience disappointment and loss of revenue and time.

What Is and Is Not Changing

Until 2006, only 4 vaccines (influenza, pneumococcal, hepatitis B [for patients at increased risk], and tetanus [as part of treatment for traumatic wounds]) were covered by Medicare under Part B. With the establishment of Medicare Part D in 2006, however, additional vaccines became covered under Part D. Even with the new, expanded coverage and access to other vaccines under Part D, however, no legal basis for plans to reimburse providers for the administration of these Part D vaccines was created.

In December 2006, President Bush signed into law the Tax Relief and Health Care Act, which introduced provisions for provider reimbursement of Part D vaccine administration fees—specifically, for such reimbursement to be under Part B in 2007 and under Part D beginning in 2008 and thereafter.

Part B vs Part D Vaccines

To understand what this means for pharmacists and physicians, a distinction first must be made between Part B and Part D vaccines. Part B vaccines include influenza, pneumococcal, hepatitis B (for individuals at high or intermediate risk), and other vaccines (eg, tetanus toxoid), when directly related to the treatment of an injury or direct exposure to a disease or condition. Reimbursement for the cost of Part B vaccines and reimbursement for their administration to the patient have been—and will continue to be—billed and reimbursed through Medicare Part B.

Thus, immunizers will continue to bill Part B contractors for both the cost of a Part B vaccine and its associated administration. These vaccines also will continue to be exempt from Part B deductibles and copays.

Part D plan sponsors, beginning in 2008, will reimburse providers for the cost of other vaccines not covered under Parts A or B and also will reimburse providers for administration of the vaccine— when receiving a particular vaccine is reasonable and necessary for the prevention of illness. Examples of planincluded vaccines, which will be listed on Part D plan formularies, are extensive.

CMS Guidelines Evolving

Specific details regarding Part D–covered vaccines, such as reimbursement rates, cost sharing, and claims filing, are still being developed. CMS has issued general guidelines and options for plans to consider, and the agency will continue to work with plans to facilitate various approaches.

For more information on vaccine billing changes under Medicare, visit the Centers for Medicare & Medicaid Services Medicare Learning Network:

Generally speaking, however, CMS believes that Part D vaccines, including the associated administration costs, should be billed as 1 claim. CMS realizes that situations may arise, however, where one provider will need to dispense a vaccine and another provider will need to administer it. CMS recommends that plans devise methods for preventing and/or identifying double billing in these situations (and alternatively, to verify that a patient has been administered a vaccine, if a claim was received for dispensing a vaccine).

Unlike Part B vaccines, deductibles and copays do apply to Part D vaccines. Also, unlike Part B vaccines, where the immunizer (pharmacist, physician, or nurse) must take assignment and is reimbursed from Medicare, it is possible that providers of Part D vaccines may not be reimbursed as network providers, but rather may assist the beneficiary in the submission of his or her claim.

Evolving models may require collection of the entire vaccine cost and administration fee (as 1 fee) from the patient and leave the patient to seek reimbursement from his or her plan. Providers should expect to see various models develop and be aware of possible plan differences.