Medicare Compliance & Reimbursement

Community pharmacists are still fairly new to health care's immunization front, but don't let that hold you back from a new source of Part D reimbursement.

Legislation signed by President Bush last December gives Medicare Part D the legal authority it needed to bring costs associated with the administration of Part D-covered vaccines under the Part D umbrella.

Billing opportunity: If you are a network pharmacy and operate in a state that allows pharmacists to administer vaccines, you will be able to bill Part D plans directly when you administer a Part D-covered vaccine to a beneficiary, effective Jan. 1.

Next year, a PDP's negotiated price for a Part D vaccine will include the vaccine ingredient cost, a dispensing fee (if applicable), sales tax (if applicable) and a vaccine administration fee.

Background: Reimbursement from the Centers for Medicare and Medicaid Services (CMS) for immunizations has been muddled in the past. Until 2006, Medicare Part B covered four vaccines: pneumococcal, flu, hepatitis B for patients at increased risk, and tetanus, when given as a part of the treatment of a traumatic wound. Part D initially had coverage for other vaccines, but only for the vaccines themselves. Until now, no law allowed CMS to pay for the act of administering the Part D covered vaccines.

Distinction: Part B will continue to cover the following vaccines and administration costs: pneumococcal pneumonia vaccine; influenza virus vaccine; hepatitis B vaccine for individuals at high or intermediate risk; and other vaccines (e.g. tetanus toxoid) directly related to the treatment of an injury or direct exposure to a disease or condition.

Formulary fix: Starting in 2008, all Part D prescription drug plans' formularies must contain all other commercially available vaccines (all those except the vaccines noted above).

"This interpretation recognizes the intrinsic linkage that exists between the vaccine and its corresponding administration, since a beneficiary would never purchase a vaccine without the expectation that it would be administered," says CMS.

Selling point: Under the new policy, pharmacists are in a position to make life easier for beneficiaries, notes pharmacist Julie Fike, manager of clinical services for Snyders Drugs in Columbia Heights, MN.

Here's why:

• If a physician administers the vaccine "out of network," the patient will typically be required to pay the physician out of pocket and seek reimbursement from the Part D plan via a paper claim.

• If an in-network pharmacy dispenses and administers the vaccine in accordance with state law, the pharmacy can process a single claim for payment by the Part D sponsor. The beneficiary will need to pay only any applicable cost-sharing amount.

Pharmacists are also able to increase access to needed vaccinations, says Fike, including the herpes zoster vaccine (see Medicare Compliance Week, Vol. 8, No. 24).

Resource: For CMS' most current guide to vaccine administration and Part D, go to www.cms.hhs.gov/MLNMattersArticles/downloads/SE0727.pdf.

For tips on stepping up your involvement, see the related article, "Give Your Business A Booster With This Plan," below.