Understanding Vaccine Billing Changes for 2008

Pharmacy Times, Volume 0, 0

Recently announced changes in vaccine reimbursement under Medicare have implications for pharmacy billing processes.

Dr. Brown works in CorporateDevelopment for Sweetbay ClinicalPrograms & Initiatives in southwestFlorida.

Pharmacists should be aware ofimportant changes in 2008 to theCenters for Medicare & MedicaidServices (CMS) policy for the reimbursementof Part D vaccine administrationfees. Many pharmacists and other practitionersare erroneously interpretingannouncements about these billingchanges to mean that all vaccine reimbursementsare shifting from MedicarePart B to Part D.

Pharmacists planning for flu clinics orthose planning to incorporate pneumococcalvaccinations into work flow(based on an incorrect assumption thatthese vaccines will be covered underPart D beginning in 2008) will experiencedisappointment and loss of revenue andtime.

What Is and Is Not Changing

Until 2006, only 4 vaccines (influenza,pneumococcal, hepatitis B [for patientsat increased risk], and tetanus [as part oftreatment for traumatic wounds]) werecovered by Medicare under Part B. Withthe establishment of Medicare Part D in2006, however, additional vaccinesbecame covered under Part D. Even withthe new, expanded coverage and accessto other vaccines under Part D, however,no legal basis for plans to reimburseproviders for the administration of thesePart D vaccines was created.

In December 2006, President Bushsigned into law the Tax Relief and HealthCare Act, which introduced provisions forprovider reimbursement of Part D vaccineadministration fees—specifically, forsuch reimbursement to be under Part Bin 2007 and under Part D beginning in2008 and thereafter.

Part B vs Part D Vaccines

To understand what this means forpharmacists and physicians, a distinctionfirst must be made between Part B andPart D vaccines. Part B vaccines includeinfluenza, pneumococcal, hepatitis B (forindividuals at high or intermediate risk),and other vaccines (eg, tetanus toxoid),when directly related to the treatment ofan injury or direct exposure to a diseaseor condition. Reimbursement for the costof Part B vaccines and reimbursementfor their administration to the patienthave been—and will continue to be—billed and reimbursed through MedicarePart B.

Thus, immunizers will continue to billPart B contractors for both the cost of aPart B vaccine and its associated administration.These vaccines also will continueto be exempt from Part B deductiblesand copays.

Part D plan sponsors, beginning in2008, will reimburse providers for thecost of other vaccines not covered underParts A or B and also will reimburseproviders for administration of the vaccine—when receiving a particular vaccineis reasonable and necessary for theprevention of illness. Examples of planincludedvaccines, which will be listed onPart D plan formularies, are extensive.

CMS Guidelines Evolving

Specific details regarding Part D–coveredvaccines, such as reimbursementrates, cost sharing, and claims filing, arestill being developed. CMS has issuedgeneral guidelines and options for plansto consider, and the agency will continueto work with plans to facilitate variousapproaches.

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



Generally speaking, however, CMS believesthat Part D vaccines, including theassociated administration costs, shouldbe billed as 1 claim. CMS realizes thatsituations may arise, however, whereone provider will need to dispense a vaccineand another provider will need toadminister it. CMS recommends thatplans devise methods for preventingand/or identifying double billing in thesesituations (and alternatively, to verifythat a patient has been administered avaccine, if a claim was received for dispensinga vaccine).

Unlike Part B vaccines, deductiblesand copays do apply to Part D vaccines.Also, unlike Part B vaccines, where theimmunizer (pharmacist, physician, ornurse) must take assignment and isreimbursed from Medicare, it is possiblethat providers of Part D vaccines maynot be reimbursed as network providers,but rather may assist the beneficiaryin the submission of his or herclaim.

Evolving models may require collectionof the entire vaccine cost andadministration fee (as 1 fee) from thepatient and leave the patient to seekreimbursement from his or her plan.Providers should expect to see variousmodels develop and be aware of possibleplan differences.