A thorough understanding of immunization billing processes for Medicare, Medicaid, and other third-party payers will be critical to ensure pharmacy staff can efficiently serve their communities and facilitate a smooth reimbursement process.
In an effort to avoid further strain on a health care system already responding to the coronavirus disease 2019 (COVID-19) global pandemic, the CDC stressed the increased importance of receiving this year’s seasonal influenza vaccination, which is recommended for everyone 6 months or older.1,2 The need to reduce this potential concurrent system strain has caused health care professionals, government officials, and research experts to use social media and news outlets to encourage patients to receive vaccines earlier in the season compared with last year. Additionally, in response to an expected increase in demand for the influenza vaccine, manufacturers plan to ramp up production and pharmacies are ready for an unprecedented busy season.1 A thorough understanding of immunization billing processes for Medicare, Medicaid, and other third-party payers will be critical to ensure pharmacy staff can efficiently serve their communities and facilitate a smooth reimbursement process. This review of third-party payer immunization guidelines includes considerations for seasonal immunizations and the COVID-19 vaccine(s) under development.
PRESCRIPTION COVERAGE AND BILLING
A large portion of patients receiving influenza and other eligible vaccines in community pharmacies have commercial health insurance with prescription coverage.3 For example, approximately 52% of children 5 years or younger are covered by private insurance.4 To successfully bill for immunizations, the pharmacy must be contracted with the patient’s specific plan. If contracted, pharmacies can typically bill for influenza and other vaccines in real time using the patient’s prescription insurance information. In some cases, the medical plan must be billed rather than the drug benefit plan, in which case the pharmacy must be contracted to bill the medical plan instead. For medical billing, an immediate adjudication response is not common, although there are billing systems available that can check eligibility and provide a cost estimate. It is important to notify these patients that they may be responsible for a future co-pay—up to the full cost of the vaccine—after their medical plan finishes the adjudication process within a couple of weeks, especially if they have not met their plan’s deductible.5
Often, a more complicated patient population to successfully bill for regarding influenza vaccines includes those with Medicare coverage, most of whom are 65 years or older. Most Medicare beneficiaries are eligible to receive 1 influenza vaccine each influenza season with direct pharmacy reimbursement by Medicare Part B or through a Medicare Advantage plan (Part C),6 assuming they choose a pharmacy that is contracted with Medicare.7 When billing Medicare Part B, pharmacies will need the patient’s identification number, which can be found on their red, white, and blue card.8 For most pharmacy software systems, Medicare Part B is not billed directly through online adjudication but rather through the mass immunization roster billing process in which a Medicare-enrolled provider, such as a pharmacy chain, works with a Medicare administrative contractor to compile a list of claims to submit through a centralized process on the pharmacy chain’s behalf.5,7 Medicare Part B covers medical and preventive services including influenza, pneumococcal, and hepatitis B vaccines.9 For these types of vaccines, there is typically zero copay for the patient. Of note, Medicare Part B will also pay for other vaccines as treatment after potential exposure has occurred, such as when a patient steps on a rusty nail and is at risk of contracting tetanus or has been bitten by an animal suspected of spreading rabies.9 For other types of regular preventive vaccines not covered by Part B, Medicare Part D may pay, assuming the patient has this coverage. However, Medicare Part D may require prior authorizations and/or additional copays for the provision of vaccinations.7
MEDICAID COVERAGE AND OUT-OF-POCKET PAYMENTS
Pharmacies should be prepared to offer immunization solutions or referrals for patients covered by local Medicaid plans. Medicaid plans do not have a standardized approach for vaccination administration and billing. Each state and county’s Medicaid plan decides which vaccines will be covered, who can provide those vaccines, and the vaccine and/or administration reimbursement rates.10 Pharmacists can familiarize themselves with the local Medicaid vaccine billing procedures, which are often available online or via a toll-free phone number.
There also will be uninsured patients and others who choose to pay for vaccinations out of pocket. As influenza symptoms may overlap with the symptoms of COVID-19, the cost of an unnecessary 2-week quarantine or the fear of needing care in overloaded health care facilities could correlate to an uptick in a patient’s willingness to pay out of pocket for the vaccine. Pharmacies can offer deals or incentives to help ease the financial burden of patients who need to pay out of pocket to receive an influenza shot. Such options include coupons or gift cards that can be used on store merchandise, as well as discount cards for the shot itself. At most big-box pharmacy chains, contracted discount cards also may give uninsured patients a price break.11
One last option for patients is to receive their influenza vaccine for free through a government agency or a nonprofit local health organization.12 For example, the CDC has taken the unusual step of purchasing 7 million doses to be distributed to states for adult vaccination.1 Furthermore, eligible children can receive vaccines at no cost through the Vaccines for Children (VFC) program.13 These free vaccines are subject to state-specific distribution and billing limitations, and many pharmacies choose not to participate because of no or very low administration reimbursement. In states paying the pharmacy an administration fee through the VFC program, these vaccines are most commonly billed through the state’s Medicaid plan.14,15
An understanding of how influenza and other vaccines are billed is important, especially when one confronts the ongoing COVID-19 global pandemic for which the country is expected to have 1 or more vaccines available soon. The Coronavirus Aid, Relief, and Economic Security (CARES) Act requires all health plans to pay the entire cost of the vaccine as a preventive health service, although it may not be covered immediately. The approved vaccine for COVID-19 would have to be recommended by the US Preventive Services Task Force, the CDC, and the Advisory Committee on Immunization Practices. When a vaccine is recommended, the CARES Act will accelerate required coverage from the standard wait of up to 1 year down to 15 days from the date of approval.16 Once the vaccine is covered, pharmacies should be able to bill using the same procedure as for other vaccinations.
The pharmacist remains a critical member of the health care system, providing vaccinations that help promote health, prevent disease, and minimize strain on other segments of the system. All pharmacy staff must be knowledgeable about the billing of various vaccines, as well as the options available to patients when they are paying for vaccines. This influenza season, pharmacists will continue to provide essential services for America’s communities, including an expected record number of influenza vaccines followed by or concurrent with a potential COVID-19 vaccination effort.
CONCHETTA LESSER, PHARMD, BCACP, is the corporate pharmacy trainer and residency program director for Albertsons Companies in Phoenix, Arizona.LINCOLN ALEXANDER, PHARMD, is a residency program director and student experiential coordinator at Albertsons Companies in Portland, Oregon. He is an alumnus of Oregon State University College of Pharmacy in Corvallis.