Medicare Compliance & Reimbursement

Part D will cover administration in 2008

Medicare Part D's new payments for vaccine administration could pave the way for a change in your role   as vaccinator.

Recently released guidance from the Centers for Medicare & Medicaid Services (CMS) outlines changes in Medicare reimbursement for vaccinations, shifting some costs covered under Part B to Part D starting next year.

Details: Called for by law, the new policy means that beginning in 2008, Medicare D prescription drug plans (PDPs) will cover administration costs for vaccines provided under the Part D drug benefit.

CMS is explicit about the impact the change could have for pharmacists:

"Where it is safe to dispense and administer vaccines in a pharmacy, [PDPs] could explore utilization of their own network pharmacists as providers of adult Medicare Part D vaccines," states the policy document from Cynthia Tudor, director of CMS' Medicare Drug Benefit Group.

A CMS e-mail accompanying the document notes that the change "presents an opportunity for pharmacists to play an expanded role in vaccine administration for Medicare Part D beneficiaries in 2008."

Pharmacists' authority to administer vaccines varies according to state laws and regulations governing pharmacy practice. At least 45 states permit vaccine administration by pharmacists as part of the scope of pharmacy practice.

Background: The Tax Relief and Health Care Act of 2006, signed into law last December, calls on CMS to require that PDPs cover the cost of vaccine administration of all Part D-covered vaccines. In 2007, Part B covered the administration costs of Part D-covered vaccines ...quot; and prior to that the fee was typically paid out-of-pocket by beneficiaries.

Watch For These Changes

The policy guidance spells out the following requirements for 2008:

• PDPs must include the cost of vaccine administration, along with the ingredient cost and any dispensing fee, in the plans' negotiated price for the vaccine.

• Prohibited: Plans cannot charge enrollees separate co-payments and co-insurance fees for vaccines and their administration.

• Not affected: The new policy does not affect Medicare payments for the administration of influenza and pneumococcal vaccines, which are Part B-covered vaccines. Hepatitis B vaccine and its administration will also continue to be covered under Part B when the vaccine is used for disease prevention in beneficiaries with an intermediate or high risk of hepatitis B infection.

• Part B will also continue to cover the costs for tetanus and other vaccines considered medically necessary for the treatment of an illness or injury.

Goal: In the guidance, CMS emphasizes that the agency wants Part D plan sponsors to "implement measures to increase access to Part D vaccines."

CMS' Abby Block indicated in a memo a year ago that the agency wanted to discourage Part D plan sponsors from designing service networks that force beneficiaries to pay the full cost of vaccines upfront and seek reimbursement later.

Block also encouraged Part D plans to provide coverage for vaccines as an "in-network" benefit for enrollees.

The CMS guidance allows PDPs to implement policies designed to determine whether a vaccine is medically necessary for plan enrollees, but cautions that plans should take into account recommendations from the Advisory Committee on Immunization Practices when assigning benefits.