Questions and Answers on 2009 H1N1 Vaccine Financing

November 30, 2009, 3:15 PM ET

General Financing Questions

Considerations of financing distinguish between those related to the vaccine itself, the ancillary supplies needed to administer the vaccine, and the actual administration of the vaccine. 

How will the 2009 H1N1 vaccine be financed?

In general, the 2009 H1N1 vaccine will be financed similarly to seasonal influenza vaccine, with two important exceptions.  First, the federal government has purchased the vaccine and related supplies so providers should not be seeking reimbursement for these.  Second, states are receiving funding from CDC to coordinate vaccination efforts.  Vaccine administration can be billed to public and private insurance in much of the same way that they currently are billed for the seasonal influenza vaccine.  In no case will commercial community vaccinators be permitted to receive both federal monies provided to public health departments and bill insurance for vaccine administration for the same patient.  Details are below, but in summary, the 2009 H1N1 vaccine will be financed similarly to the seasonal influenza vaccine.

Can vaccination providers charge or bill for the 2009 H1N1 vaccine?

No. 2009 H1N1 influenza vaccine and ancillary supplies (syringes, needles, sharps containers, and alcohol swabs) have been purchased by the federal government and provided free of charge to all providers participating in this voluntary vaccination effort. Therefore, it will not be permissible to charge for the 2009 H1N1 vaccine itself.

Can vaccination providers charge or bill for administration of the 2009 H1N1 vaccine to patients?

Yes. While every effort is being made to ensure that cost is not a barrier for patient receipt of vaccine, providers may charge or bill for vaccine administration. Policies and procedures guiding this financial transaction are explained below.

What types of providers can administer the 2009 H1N1 vaccine?

Any public or private provider who is designated as a 2009 H1N1 vaccinator by the public health authority in the jurisdiction where they practice can participate in the 2009 H1N1 vaccination program. In addition to physicians, private providers may include commercial community vaccinators (CCV) such as pharmacies, retail-based clinics, urgent care centers, and medical services firms. Public providers may include state and local health departments and Health Centers (HCs), including any federally qualified health center (FQHC) whether public or private.

To become a designated 2009 H1N1 vaccinator, providers should contact the appropriate person in their state health department for more information (http://www.cdc.gov/h1n1flu/vaccination/statecontacts.htm). It is not necessary to be a registered Vaccines for Children (VFC) provider in order to participate in the 2009 H1N1 vaccination program.

Public Health Departments

Can federal funds provided to public health departments for 2009 H1N1 vaccine implementation be used to pay for the administration of vaccines given by commercial community vaccinators?

Yes. Federal funds have been awarded for vaccine campaigns in accordance with state plans and the terms and conditions of the grant award. Providers should contact their state health departments for the specifics of the vaccination campaign in each state. In no case will commercial community vaccinators (CCVs, as defined above) be permitted to receive both federal monies provided to public health departments and bill insurance for vaccine administration for the same patient. It is the responsibility of the designated public health authority to oversee this policy. Following the 2009 H1N1 vaccination campaign, HHS will conduct an assessment to determine how this process was followed.

By what mechanisms may public health departments use federal implementation funds to pay for the administration of 2009 H1N1 vaccines given by commercial community vaccinators?

When a contract exists between the commercial community vaccinator and the public health department, the public health department can organize a 2009 H1N1 vaccination clinic using the contracted CCV to provide staff or to run the clinic. The public health department may use 2009 H1N1 vaccine implementation funds provided by the federal government to pay the CCV. Alternatively, the public health department may organize and establish a mass vaccination site and identify a CCV to administer vaccine at that site. In this case, a health department may use federal funds to pay the CCV, or the CCV can bill third party payers, including Medicare, Medicaid and private health insurance plans.

Private Health Insurance

Will private health insurance plans reimburse private providers for administration of 2009 H1N1 vaccine?

This is up to each individual health plan, but the general expectation is that plans will reimburse for vaccine administration.  According to America’s Health Insurance Plans, a national association representing nearly 1,300 companies that provide health insurance to over 200 million Americans,  “Every year health plans contribute to the seasonal flu vaccination campaign in several ways:

a) Health plans communicate directly with plan sponsors and members about the current Advisory Committee on Immunization Practices (ACIP) recommendations and encourage immunization; they also provide information on where to get vaccinations, and who to contact with any questions.

b) Just as health plans have provided extensive coverage for the administration of seasonal flu vaccines in the past, public health planners can make the assumption that health plans will provide reimbursement for the administration of 2009 H1N1 vaccine to their members by private sector providers in both traditional settings e.g., doctor’s office, ambulatory clinics, health care facilities, and in non-traditional settings, where contracts with insurers have been established.”

What Current Procedural Terminology (CPT) codes are available for submitting a claim for administration of 2009 H1N1 vaccine to a private health insurance plan?

The currently established CPT code for 2009 H1N1 vaccine is 90663 (influenza virus vaccine, pandemic formulation, H1N1). This code may be reported in conjunction with the unique CPT code for H1N1 vaccine administration:  90470, H1N1 immunization administration (intramuscular, intranasal), including counseling when performed. Providers should follow instructions provided by the health plans with whom they contract related to billing for 2009 H1N1 vaccine administration.

Medicare Fee for Service (FFS)

Will Medicare FFS pay private providers for administration of 2009 H1N1 vaccine?

Yes, like the seasonal influenza vaccine, the 2009 H1N1 vaccine and its administration are covered under the Part B preventive services benefit for all Medicare beneficiaries with Part B coverage. For details on Medicare coverage and reimbursement for 2009 H1N1 vaccine, see Medicare Fee-for-Services (MFFS) Billing for the Administration of the Influenza A (H1N1) Virus Vaccine.

Will Medicare FFS pay for multiple administration fees if it is determined that the 2009 H1N1 vaccine requires multiple doses?

It is expected that persons aged 10 and over only require one dose of 2009 H1N1 vaccine. However, multiple administration fees will be covered for Medicare beneficiaries requiring multiple doses of H1N1 vaccine.

What type of cost-sharing for 2009 H1N1 vaccine administration will be imposed on Medicare FFS beneficiaries?

For Medicare FFS beneficiaries, co-insurance and deductible requirements are not applied to influenza vaccine administration, including 2009 H1N1.

How much will Medicare FFS pay for administration of 2009 H1N1 vaccine?

Medicare FFS will reimburse the administration of 2009 H1N1 influenza vaccine at the same rate that is paid for administration of seasonal influenza vaccine, for each dose administered.

What codes should be used when submitting a claim for 2009 H1N1 vaccine administration to Medicare FFS?

CMS has established two new Healthcare Common Procedure Coding System (HCPCS) codes for 2009 H1N1 vaccine and vaccine administration: G9141- Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family), and G9142- Influenza A (H1N1) vaccine, any route of administration.

Providers may elect to submit the HCPCS code for the 2009 H1N1 vaccine along with the vaccine administration code. However, since Medicare FFS will not provide payment for the 2009 H1N1 vaccine itself, only the vaccine administration code is required for payment.

Will Medicare pay for 2009 H1N1 vaccine administration in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?

Yes. Medicare will pay 100% of the administration cost, through the cost report. These costs will appear on the applicable cost report for the cost reporting period for which the H1N1 vaccine was administered.

Will Medicare cover 2009 H1N1 vaccine administered by a physician in a setting such as a pharmacy or a grocery store?

Yes. Influenza vaccinations can be provided in a wide range of locations. Physicians must enroll with the Medicare carrier or Medicare Administrative Contractor that processes claims for the area where the service is performed.

Can mass immunizers roster bill Medicare for administration of 2009 H1N1 vaccine?

Yes. Seasonal influenza mass immunizers and roster billers may submit 2009 H1N1 administration claims using the roster billing format. The same information must be captured for the 2009 H1N1 administration roster claims as it is for the seasonal influenza roster claims.

Medicaid and CHIP (Children’s Health Insurance Program)

Will Medicaid/CHIP pay for administration of 2009 H1N1 vaccine?

Medicaid will pay for administration of 2009 H1N1 vaccine to all Medicaid-enrolled children under the age of 21. Administration of 2009 H1N1 vaccine to all children covered by separate state CHIP programs will also be paid for by Medicaid. For adults in the Medicaid program, 2009 H1N1 vaccine administration is a covered service when furnished by a participating provider under the mandatory section 1905(a) Medicaid benefit. Since hospital, physician and federally qualified health center/rural health clinic (FQHC/RHC) services are mandatory Medicaid benefits, 2009 H1N1 vaccine administration would be a covered service when provided by these participating providers.

What type of cost-sharing for 2009 H1N1 vaccine administration will be imposed on Medicaid/CHIP beneficiaries?

The following categories of beneficiaries are exempt from copayments: pregnant women; children under 18; patients in a hospital, nursing facility, or intermediate care facility/mentally retarded; and terminally ill patients receiving hospice care.  States can impose nominal copayments on other beneficiaries.  Approximately 27 states require some cost sharing for adult immunizations.  However, CMS is encouraging states that currently impose copayments for services required for prevention, diagnosis, or treatment of the 2009 H1N1 influenza (e.g., vaccine administrations or treatment of 2009 H1N1 influenza as part of an office visit to a physician or other provider type) to submit state plan amendments (SPAs) to exclude services related to 2009 H1N1 influenza from copayments. 

Copayments and other out-of-pocket charges should not be collected in public health clinics. More information is available at H1N1 Vaccine Administration Billing Q & As.

How much will Medicaid/CHIP pay for administration of 2009 H1N1 vaccine?

Medicaid and CHIP payments for administration of 2009 H1N1 vaccine will be similar to payments for other vaccines given to Medicaid beneficiaries. These payments are determined by each state Medicaid program, and vary by state.

Will Medicaid pay for 2009 H1N1 vaccine administered in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC)?

Yes. FQHCs and RHCs services are mandatory Medicaid benefits, so 2009 H1N1 vaccine administration provided by these participating providers is a covered service. Medicaid FQHC and RHC payment methodologies and payment rates vary across states. CMS will then match the state's expenditure at the appropriate matching rate.

Can mass immunizers roster bill Medicaid for administration of 2009 H1N1 vaccine?

Roster billing is not precluded under federal law, and there are States that have been accepting roster billing for other immunizations, mainly in the context of nursing facilities.  Each state has its own billing rules/requirements. States have been encouraged by CMS to allow providers to “roster bill” for vaccines, which would allow providers to submit one claim identifying all eligible Medicaid and CHIP beneficiaries that receive the 2009 H1N1 vaccine on a given day. Roster billing may be useful for providers conducting school-located vaccination clinics or other types of mass vaccination clinics.

Will 2009 H1N1 vaccination in a setting such as a pharmacy or a grocery store be covered by Medicaid?

To the extent that States have not done so already, States are encouraged to expand coverage for vaccine administration to a range of providers and settings, including non-traditional care sites, in order to efficiently and effectively provide vaccinations to large numbers of Medicaid and CHIP beneficiaries. These could include walk-in clinics at retail stores/outlets/pharmacies and school-based health centers/clinics. Other ways for States to consider expanding their capacity to cover/provide mass vaccinations would be to establish clinics under physician direction at schools. Note that Federal requirements pertaining to clinic services at 42 CFR 440.90 require that services be provided “under the direction of a physician.” Physician direction can be met, in the case of vaccinations, through standing orders provided by the physician or other forms/mechanisms of indirect physician direction/supervision where the physician is not necessarily on-site. The physician must, however, assume professional responsibility for the service/vaccinations provided by those under his/her direction and be readily available for direction/consultation.

Depending on the State’s current State Medicaid or CHIP plan, a state plan amendment (SPA) may be required to effectuate some of these options to expand provision of and access to 2009 H1N1 vaccinations. CMS will assure that such SPAs are acted upon promptly and expeditiously.

What is Medicaid’s role in 2009 H1N1 vaccine administration?

CMS recently issued guidance to States outlining existing Medicaid and CHIP authorities available to States for the administration of 2009 H1N1 vaccine. States should consult the guidance at the following link to address concerns that may arise regarding Medicaid and 2009 H1N1 vaccine administration: "State Health Official Letters"

What should State Medicaid programs do with regard to the new H1N1 codes that have recently been published?

Four new codes plus one revised code were recently published and are available for use by providers and health insurers in submitting/reimbursing claims for H1N1-related services. These codes become part of the standard medical code sets which are used by providers and health insurers, public and private, in transacting electronic medical claims under HIPAA. Two new G-HCPCS codes were published, effective September 1, 2009. Both codes, G9141 for H1N1 immunization administration and G9142 for H1N1 vaccine, were added to Medicare’s October 2009 update of their physician fee schedule. Effective September 28, 2009, CPT created new code 90470 for H1N1 immunization and revised code 90663 to read “Influenza virus vaccine, pandemic formulation, H1N1.” Also, effective October 1, 2009 a new ICD-9-CM diagnosis code was established for H1N1 (488.1).

These new and revised codes will enable State Medicaid agencies and their providers to identify, track and transact claims specifically for H1N1-related services. We recognize that it takes time and funding to notify providers and make the appropriate system changes to accommodate these new codes, but we strongly encourage States to use these codes to identify, track and transact claims for these services.

VA

Will the VA cover administration of 2009 H1N1 vaccine for Veterans eligible for VA health care benefits?

Yes, the VA will provide the 2009 H1N1 vaccine to Veterans who are enrolled in the VA health care system. There will be no charge to eligible Veterans for administration of H1N1 vaccine. Veterans seeking the H1N1 vaccine but currently not enrolled in VA health care can apply for enrollment at their closest VA health care facility, or online at: "Application for Medical Benefits"

TRICARE

Will TRICARE cover administration of 2009 H1N1 vaccine for its beneficiaries?

Yes, TRICARE will cover the 2009 H1N1 vaccine for TRICARE beneficiaries.  This coverage applies to beneficiaries served both in Military Treatment Facilities and in private provider offices that are authorized to treat TRICARE beneficiaries.

What type of cost-sharing for 2009 H1N1 vaccine administration will be imposed on TRICARE beneficiaries?

Cost-sharing for 2009 H1N1 vaccine administration will be similar to cost-sharing for other vaccines covered by TRICARE. This cost-sharing may vary depending on what type of TRICARE coverage the beneficiary has. TRICARE beneficiaries should consult their benefits guide for cost-sharing information.

What codes should be used when submitting a claim for administration of 2009 H1N1 vaccine to TRICARE?

The currently established CPT code for 2009 H1N1 vaccine is 90663 (influenza virus vaccine, pandemic formulation, H1N1). This code may be reported in conjunction with the unique CPT code for H1N1 vaccine administration: 90470, H1N1 immunization administration (intramuscular, intranasal), including counseling when performed. Providers should follow instructions provided by the health plans with whom they contract related to billing for 2009 H1N1 vaccine administration.

CMS has established two new HCPCS codes for 2009 H1N1 vaccine and vaccine administration: G9141- Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family), and G9142- Influenza A (H1N1) vaccine, any route of administration.

Special Populations

Will screening of children for VFC eligibility be required prior to administration of 2009 H1N1 vaccine?

No.

Will administration of 2009 H1N1 vaccine to eligible tribal members be covered by IHS?

Yes, the IHS will cover administration of the 2009 H1N1 vaccine to tribal members who are eligible for IHS health care benefits. There will be no charge to eligible tribal members for administration of 2009 H1N1 vaccine.

Commercial Community Vaccinators (CCV)

Are CCV who have not contracted with a public health department to provide staff or to run a public health vaccination clinic permitted to administer 2009 H1N1 vaccine?

Yes, a CCV can act as a private provider as long as the CCV has been designated as a 2009 H1N1 vaccinator by the jurisdiction in which it operates. If a CCV organizes a clinic outside of a contract with the public health department to provide staff or to run the vaccination clinic, the CCV may charge patients or bill insurance to recoup the costs of vaccine administration.

Will 2009 H1N1 vaccination in a setting such as a pharmacy or a grocery store be covered by private health insurance plans?

Yes, health insurance plans providing coverage for influenza vaccinations will reimburse the administration of 2009 H1N1 vaccine provided in a setting if the vaccinator/site has an established contract with that insurer. In addition, many CCVs, including urgent care centers, retail-based clinics, and mass vaccinators, already have contracts in place with health insurance plans that can be used for reimbursement purposes. Appropriately licensed and credentialed CCV and pharmacies who seek reimbursement from health insurance plans should work with national, regional, and local insurance plans in anticipation of 2009 H1N1 vaccination.

Uninsured

Where can persons who are uninsured or underinsured receive 2009 H1N1 vaccine?

In addition to public health departments and the mass vaccination clinics they sponsor, Federally Qualified Health Centers (FQHCs), also known as Section 330-funded Health Centers (HCs), receive federal funding to provide healthcare to underserved populations, regardless of ability to pay, It is expected that the costs associated with administering 2009 H1N1 vaccine to existing health center patients would be borne by the health centers as part of the general expectations of their grants. As with all services they provide, Health Centers may charge a small fee.  However, public health departments are encouraged to provide funding to FQHCs and other types of HCs to cover the costs of vaccinating uninsured persons who are not health center patients, but who seek 2009 H1N1 vaccination at these clinics as an alternative to other vaccination providers. For health centers in your area, visit "Find a Health Center". Additionally, providers may elect to provide the vaccine to uninsured or underinsured persons without charging an administration fee.

Who will pay for the administration of 2009 H1N1 vaccine of uninsured or underinsured persons?

Federal funds are being provided to public health authorities to ensure that uninsured or underinsured persons can receive H1N1 vaccine free of charge (see above).  Patients without insurance coverage for 2009 H1N1 vaccine may be vaccinated in a private provider’s office if they are willing to pay the vaccine administration fee out of pocket, or if the provider chooses to administer the vaccine without charge.  Patients who cannot afford to pay a vaccine administration fee are encouraged to seek vaccination through their public health department, mass vaccination clinic, or through a CCV. 

Will private providers be able to charge patients for vaccine administration if they are uninsured?

Yes, private providers may charge a fee for the administration of the vaccine to the patient. Should they choose to charge an administration fee, the fee may not exceed the regional Medicare payment rate for seasonal influenza vaccine administration.  If the patient is unable to pay, the provider may choose to administer the 2009 H1N1 vaccine for free or for a reduced fee. Providers are encouraged to ensure that cost is not a barrier to vaccination.