Managing Costs

When you are setting up an immunization program in your practice, it is important to investigate third party coverage for the costs and administration of the immunizations you plan to offer. Patients may be enrolled in employer-provided health insurance plans, or private insurance plans that have limited vaccine reimbursements for physicians. It is important to communicate with the insurance carriers most often used by the patients in your practice to verify vaccine coverage and administration. Reimbursement varies by insurance carrier. Tracking payment of insurance claims is an invaluable tool in assessing coverage for immunization services. Correct coding helps ensure that a practice receives payment for vaccines given to patients. See the coding page for more detailed information about immunization coding.

Under the Affordable Care Act (ACA) vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), are required to be provided with no-cost sharing (i.e. no co-pay) for children, adolescents, and adults. Check the list of vaccines covered for more information about the ACA.

Federal regulations require all CDC recommended vaccines and routine immunization coverage of persons up to 21 years of age covered under the Medicaid program and the Children’s Health Insurance Program (CHIP). This coverage is for low-income families and which families are covered varies on a state-by-state basis.

Medicare Part B, the federal program for those over 65 or disabled, currently covers the administration of three vaccines: influenza (once per influenza season), pneumococcal polysaccharide and booster for high risk persons (once per lifetime), and hepatitis B. Medicare Part D does not cover other immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition (e.g. tetanus, rabies exposure). Additional information about the Medicare Part B/Part D coverage differences can be found by clicking the following links.

Your practice may be able to obtain free or discounted vaccines to reduce initial and overhead costs. Vaccines for Children (VFC) is a federal program that provides free vaccine for all persons from birth through 18 years (until their 19th birthday) who meet VFC criteria. Contact the VFC coordinator at your local and state health department for eligibility requirements for patients in this age range. The VFC website has helpful information addressed to providers. As an added benefit, the state immunization program staff may be able to provide on-site assistance in setting up your office immunization program. Another useful strategy is to join with other providers for bulk or group purchasing which generally lowers the per-unit costs of vaccines and supplies.

Purchasing Options

While there are many costs associated with purchasing and administering vaccines, there are ways for ob-gyn offices to manage these costs in order to cover overhead. For additional information about Group Purchasing Organizations, Physician Buying Groups, and “Questions to Ask” if you are considering joining a GPO or PBG, visit the American Academy of Pediatrics page on the topic.

For updated vaccine costs, visit CDC’s vaccine price list.

Affordable Care Act

Part of the Affordable Care Act allows for preventative services that benefit women, pregnant women, children, adolescents, and other adults. Under the ACA there are several vaccines that are provided with no-cost sharing (i.e. no co-pay) for children, adolescents, and adults. Those vaccines include:

Children

  • Diphtheria, Tetanus, Pertussis
  • Haemophilius influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Quadrivalent Human Papillomavirus vaccine
  • Inactivated Poliovirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Rotavirus
  • Varicella

Adults

  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Quadrivalent Human Papillomavirus vaccine
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella

For additional information, please click here.

As part of the Affordable Care Act (ACA) immunizations including human papillomavirus (HPV), influenza (flu), and tetanus, diphtheria, and pertussis (Tdap) are required to be covered at no charge for women, including those who are pregnant or nursing. These requirements apply to all non-grandfathered private health insurance plans and went into effect in the first full plan year beginning on or after September 23, 2010. For additional detailed information on the Affordable Care Act and Women’s Health visit Healthcare.gov or read the ASPE Issue Brief.

FAQs about Affordable Care Act Implementation (Part XII) prepared jointly by the Departments of Labor, Health and Human Services (HHS), and the Treasury and published February 20, 2013.

  • The Advisory Committee on Immunization Practices (ACIP) section (see pg. 5) clarifies that for vaccines with permissive (Category B) recommendation, if the vaccine is prescribed by a health care provider consistent with the ACIP recommendations, a plan or issuer is required to provide coverage for the vaccine without cost-sharing. This clarification was made following publication of the HHS interim final rule regarding coverage of preventive services under the ACA, which references coverage for “immunizations for routine use”.

See more information at the ACOG Health Reform Action Center and resources from the National Health Law Program and a Q&A on preventive services for women.

In addition to any Advisory Committee on Immunization Practices (ACIP)-recommended immunizations, the ACA requires that the following services be covered by the plan without co-pay and and/or deductibles to the patient:

  • United States Preventive Services Task Force A and B-rated services.
  • Services detailed in the Bright Futures program for health promotion and disease prevention in children and adolescents, and
  • Additional services for women which include:
           - Well-woman visits.
           - Gestational diabetes screening.
           - Domestic and interpersonal violence screening and counseling.
           - FDA-approved contraceptive methods, and contraceptive education and counseling. 
           - Breastfeeding support, supplies, and counseling. 
           - HPV DNA testing, for women 30 or older.
           - Sexually transmitted infections counseling for sexually-active women.
           - HIV screening and counseling for sexually-active women.

 

Additional Resources

The National Adult and Influenza Immunization Summit's NEW Coding and Billing resource addresses the top questions identified by the Access and Provider Workgroup on coding and/or billing for adult vaccinations, scenarios that detail how to go about coding and billing for adult vaccines, and collected resources on this topic from the Summit's medical association, public health, and vaccine manufacturing partners. 

The National Adult and Influenza Immunization Summit released a factsheet on how to use immunization activities to obtain points for the MIPS/MACRA Quality Payment Program.

 

 
Updated 5/21/17

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