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Watch for reimbursement changes for vaccines

APCs Weekly Monitor, July 20, 2007

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QUESTION: I heard that CMS is changing the way it reimburses vaccines. Can you provide any additional information?

ANSWER: Medicare published a Medlearn Matters article (SE0727) in which it made some significant changes regarding reimbursement of vaccines. You can read the complete article at the CMS Web site.

Following is a summary of some of the highlights:

1. Medicare will only reimburse facilities for the following vaccines:

• Flu
• Pneumonia
• Hepatitis B for immediate and high-risk patients
• Other vaccines (e.g., tetanus toxoid) when directly related to the treatment of an injury or direct exposure to a disease or condition

2. Medicare will no longer reimburse facilities for administering a Part D vaccine beginning on January 1, 2008. The new 2007 G code for administering a Part D vaccine (G0377) will be deactivated on December 31, 2007.

3. Beginning on January 1, 2008, the Part D program will cover vaccine administration costs associated with Part D vaccines. Thus, the coverage available in 2007 under Part B will cease, and Medicare will provide reimbursement solely under Part D.

4. CMS' approach was based on the fact that most vaccines of interest for the Medicare population (e.g., influenza, pneumococcal, and hepatitis B for intermediate and high-risk patients) were covered and remain covered under Part B. For vaccines that are not covered under Part B, the beneficiary must pay the physician and then submit a paper claim to his or her Part D plan for reimbursement, up to the plan's allowable charge. In the absence of communication with the plan prior to vaccine administration, the amount the physician charges may be different from the plan's allowable charge, and a differential may remain that the beneficiary must pay.

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