The ACA’s Impact on Vaccine Administration and Reimbursement

The Affordable Care Act enacted by President Obama in 2010 not only provides sweeping coverage for Americans who are uninsured or underinsured, but it has implications for healthcare providers as well. The regulations set forth by the U.S. Departments of Health and Human Services (HHS), Labor and the Treasury require that any individual or family enrolled in a new health insurance plan on or after September 23, 2010, be provided the recommended preventive services without a deductible, co-payment or co-insurance. By 2013, the number of Americans who will qualify for these benefits is estimated to be 78 million, and it is estimated that 88 million overall will eventually benefit from the new policy.

This preventive care access, without co-pays or cost sharing (as long as the care is provided by an in-network provider), now mandates Advisory Committee on Immunization Practices (ACIP) recommended vaccines.¹ The ACIP, an independent advisory panel, makes these recommendations to the U.S. Centers for Disease Control and Prevention (CDC), and in the past, it has greatly influenced the vaccine coverage provided by both private and public insurers. The new mandate will require increased funding, though the cost expenditure is expected to be offset by savings with disease prevention.

Congress has appropriated large sums of money to fund these initiatives, including $1 billion in funding for wellness and prevention programs, with $300 million of that money set aside for the Section 317 immunization program,² which provides federal money to vaccine infrastructure programs at the federal, state and local levels.

What does this mean for healthcare providers? They will see an increase in the number of patients seeking preventive care, a change in how they can bill for that care, as well as changes in how care is reimbursed by government and private insurance.

Outpatient Settings

It is estimated that Medicaid covers between 40 percent and 90 percent of patients seeking immunizations, and private insurance covers 7 percent to 55 percent.³ To maximize an immunization’s reach, the ACA recommends that only government-provided vaccines be used for Medicare patients, and private-purchase vaccines be used for those with private insurance carriers for both the billing of the vaccine itself, as well as the administration fee. This approach is designed to preserve government resources for those with public insurance, as well as open a revenue stream from patients with private insurance.³

It was found in a 2001 survey that 70 percent of health departments did not bill private insurance for the administration and delivery of vaccines, 3 which means a significant loss in revenue, especially since Medicare payment updates lag behind medical inflation.⁴ However, under the ACA, appropriately billed immunization services will be reimbursed by both private and public insurance, and administrative standardizations such as using roster billing, chart reminders and standing orders may substantially reduce the administration costs of delivery.

The roster billing methodology was developed to allow for simplified billing of the influenza vaccine and pneumococcal polysaccharide vaccine (PPV), and it does not provide for office services or any other administration fees. With these rosters, one claim can be submitted to Medicare daily for all flu and PPV vaccine recipients, provided two or more Medicare beneficiaries are immunized. Both paper billing (a separate CMS-1500 claim form must be submitted) and electronic billing (using HIPAA-adopted ASC X12N 837 claim standard) are acceptable to submit for Medicare Part B reimbursements.⁵

The Centers for Medicare and Medicaid Services (CMS) has approved Medicare reimbursement for only a few outpatient services deemed to be a reasonable cost, one of which is the flu vaccine. Yet, because of the fluctuations in composition of the flu vaccine from year to year, the CMS is unable to set a prospective payment because those fluctuations in yearly costs could make the vaccine unaffordable to hospitals and outpatient service centers and, thus, undeliverable from a business standpoint. 6 However, because CMS pays for the flu vaccine at a reasonable rate, it does not fall under the set Outpatient Prospective Payment System (OPPS) rates.And, the flu vaccine, which falls under the Category 1 CPT code set (which identifies the servicesrendered),will continue in 2012 as code 4120-01-C. 6 Category 1 CPT vaccine codes are updated twice yearly and implemented in the January and July quarterly updates.

Department of Defense Pharmacy Benefits Expanded

The Department of Defense recently authorized Tricare retail network pharmacies to administer all Tricare-approved vaccines, in accordance with state laws, in the pharmacy setting, bringing Tricare in line with policies of many insurance companies. Previously, only three vaccines — seasonal influenza, H1N1 and the pneumococcal vaccines — were authorized. Now, Tricare basic and prime enrollees are authorized to receive CDC-approved vaccines as published in the Morbidity and Mortality Weekly Report (MMWR) for those ages 6 months and older, as well as vaccines required for overseas travel as part of active duty military personnel’s assignment.

Tricare also expanded the vaccines approved by Medicare Part B, which was limited to invasive pneumococcal disease, hepatitis B and influenza.As part of Tricare’s pharmacy benefit, the claims processing of vaccine administration will be greatly simplified. Because the negotiated fee by the Tricare pharmacy benefits manager is lower than that of the nationwide administration fee for Medicare Part B vaccines, the patient will have a $0 co-pay.⁷

Pediatrics

CMS revised the reporting of immunization administration for pediatric patients in order to better align with the evolving best practice model of delivering combination vaccines. Effective January 1, 2011, the reporting and payment for these services was structured on a per-antigen basis rather than a per-vaccine (combination of toxoids) basis as it was in prior years.

Further, based on negative comments regarding this CMS ruling’s proposed work, CMS referred CPT codes 90460 and 90461 (immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health professional; each additional vaccine/ antigen component) to the multispecialty refinement panel for further review. That panel ruled at work relative value units (RVUs) — used to calculate compensation for physicians using a set formula tied to various services — of 0.17 for CPT Code 90460 and 0.15 for CPT code 90461.⁸

The National Vaccine Advisory Committee (NVAC) recommends that the CDC provide support for the development of billing mechanisms for insured children and adolescents who are cared for in the public sector, as well as technical assistance for the development of these billing mechanisms. It also encourages that any reimbursements received be reinvested in local immunization programs.⁹ The CDC is investing funds for the development of billing programs, which are in development in certain communities, through a Billables Grant Project. In 2011, the Affordable Care Act Prevention and Public Health Fund provided $13 million in 2011 to grantees for this purpose.⁹

Administration Fees

The CMS deemed in 1994 that lower administration fees should be set for the Vaccines For Children (VFC) program. It further stipulated in the Social Security Act, Section 1928(c) (2)(C)(ii),that administration fees may be charged for qualified pediatric vaccines under the VFC program as long as that fee “in the case of a federally vaccine-eligible child does not exceed the costs of such administration (as determined by the Secretary based on actual regional costs for such administration).”¹⁰ However, a vaccine-eligible child may not be denied a pediatricqualified vaccine due to inability to pay the administration fee. Administration fee caps are for VFC children only and not for those who fall under private insurance programs.

Another rule by the CMS in 2012 requires that vaccine administration fees, which are billed separately from the dispensing of a vaccine, be excluded from cost-sharing reductions in the coverage gap, or actual cost minus dispensing and administration fees.¹¹ Providers administering vaccines under the VFC program should use code 90460. Code 90461 is used for a vaccine with multiple antigens and should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled and non-Medicaid-enrolled VFCentitled children.¹⁰ And, providers may not send unpaid vaccine administration bills to collections should a parent be unable to pay. However, an unpaid office visit fee may be sent to collections.

Medicare ePrescribe Penalty

One note of concern to physicians with regard to the receipt of Medicare payments is the new ePrescribing penalty that took effect January 1, 2012. This penalty states that those who do not successfully participate in the ePrescribe program and who have not successfully applied for an extension or exemption will be penalized with a 1 percent payment reduction for all Medicare claims based on the 2012 fee schedule amounts.

Certain exemptions include being registered to participate in the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program in which the adoption of certified EHR technology was required by October 1, 2011, as well as others. And, there is no appeal process to this request for exemption.¹²

Preventive Healthcare Needed for All

The changes to the new healthcare law continue to unfold, and one can expect controversy on both sides based on perception of the law. One thing is certain, however: The need to care for those who have financial constraints, some severe, has never been greater. As such, preventive care provided to those who are under- and uninsured will enable preventive healthcare for all.³