Carrier/AB MAC Payment Requirements (Rev. 1586, 10-06-08)

by  Jared Staheli
June 25th, 2015

Payment for pneumococcal, influenza virus, and hepatitis B vaccines follows the same standard rules that are applicable to any injectable drug or biological. (See chapter 17 for procedures for determining the payment rates for pneumococcal and influenza virus vaccines.)

Effective for claims with dates of service on or after February 1, 2001, §114, of the Benefits Improvement and Protection Act of 2000 mandated that all drugs and biologicals be paid based on mandatory assignment. Therefore, all providers of influenza virus and pneumococcal vaccines must accept assignment for the vaccine.

Prior to March 1, 2003, the administration of pneumococcal, influenza virus, and hepatitis B vaccines, (HCPCS codes G0008, G0009, and G0010), though not reimbursed directly through the MPFS, were reimbursed at the same rate as HCPCS code 90782 on the MPFS for the year that corresponded to the date of service of the claim.

Prior to March 1, 2003, HCPCS codes G0008, G0009, and G0010 are reimbursed at the same rate as HCPCS code 90471. Assignment for the administration is not mandatory, but is applicable should the provider be enrolled as a provider type “Mass Immunization Roster Biller,” submits roster bills, or participates in the centralized billing program.

Carriers/AB MACs may not apply the limiting charge provision for pneumococcal, influenza virus vaccine, or hepatitis B vaccine and their administration in accordance with §§1833(a)(1) and 1833(a)(10)(A) of the Social Security Act (the Act.) The administration of the influenza virus vaccine is covered in the influenza virus vaccine benefit under §1861(s)(10)(A) of the Act, rather than under the physicians’ services benefit. Therefore, it is not eligible for the 10 percent Health Professional Shortage Area (HPSA) incentive payment or the 5 percent Physician Scarcity Area (PSA) incentive payment.

No Legal Obligation to Pay

Nongovernmental entities that provide immunizations free of charge to all patients, regardless of their ability to pay, must provide the immunizations free of charge to Medicare beneficiaries and may not bill Medicare. (See Pub. 100-02, Medicare Benefit Policy Manual, chapter 16.) Thus, for example, Medicare may not pay for influenza virus vaccinations administered to Medicare beneficiaries if a physician provides free vaccinations to all non-Medicare patients or where an employer offers free vaccinations to its employees. Physicians also may not charge Medicare beneficiaries more for a vaccine than they would charge non-Medicare patients. (See §1128(b)(6)(A) of the Act.) When an employer offers free vaccinations to its employees, it must also offer the free vaccination to an employee who is also a Medicare beneficiary. It does not have to offer free vaccinations to its non-Medicare employees.

Nongovernmental entities that do not charge patients who are unable to pay or reduce their charges for patients of limited means, yet expect to be paid if the patient has health insurance coverage for the services provided, may bill Medicare and expect payment.

Governmental entities (such as PHCs) may bill Medicare for pneumococcal, hepatitis B, and influenza virus vaccines administered to Medicare beneficiaries when services are rendered free of charge to non-Medicare beneficiaries.

References:

Carrier/AB MAC Payment Requirements (Rev. 1586, 10-06-08). (2015, June 25). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/carrier-ab-mac-payment-requirements-rev-1586-10-06-08-26906.html

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