Vaccine Reimbursement Guidelines for Home Health Agencies

As agencies gear up for the 2016-2017 influenza season, questions often arise regarding the reimbursement rates and coverage policies for providing the flu vaccine to home health patients and the community.

Influenza vaccines are reimbursed under the Medicare Part B vaccine benefit. Home health agencies (HHAs) may not bill for the vaccine and its administration on a home health claim-type of bill (TOB) 32x. HHAs bill for the vaccine and its administration using the home health claim TOB 34x regardless if the vaccine is provided to a home health patient or a patient in the community. HHAs may also Roster bill for providing influenza vaccines. See the Medicare Claims Processing Manual,chapter 18, for Medicare payment policies related to the influenza vaccine.
There are two payment rates agencies must consider when providing vaccines: payment for the vaccine itself and payment to administer the vaccine.
HHA are reimbursed for the vaccine on a reasonable cost basis. Other than application of the lower costs or charges provision, Medicare recognizes the reasonable, allowable cost for the vaccine.
If, however, the Medicare contractor believes that the HHA has unreasonably incurred cost for the vaccines—or otherwise has not been a prudent buyer—it is up to the HHA to support that the costs are reasonable. If it cannot, the contractor will not recognize the unreasonable portion of the incurred cost.
Reimbursement for the vaccine administration for HHAs is based on the outpatient prospective payment system (OPPS) vaccine administration rate, which is determined each calendar year (CY). Sixty percent of the rate is wage adjusted using the hospital wage index for the core based statistical area (CBSA) where the service is provided. The 2016 OPPS rate for the influenza vaccine administration is $30.87.  A new rate for CY 2017, beginning January 1, 2017, will be issued with the final payment rule for the OPPS.
To determine the amount the HHA will be reimbursed for the vaccine administration, the agency will need to use the hospital wage index that applies to the CBSA where the service is furnished and adjust 60 percent of the national unadjusted payment for vaccine administration by the applicable wage index.
For example, the 2016 national unadjusted payment rate is $30.87. If the hospital wage index for the applicable CBSA is .99, payment to the HHA will be $30.68:
  • $30.87*.6 = $18.522 (the portion to be wage adjusted);
  • $18.522 *.99 (the wage index) =$18.33678 (the wage adjusted portion of the payment);
  • $18.33678 + $12.348 (the 40% of the national unadjusted payment that is not wage adjusted) = $30.68 (after rounding).

Click herefor the Med Learn Matters© “QUICK REFERENCE INFORMATION: Medicare Immunization Billing” for influenza vaccine and vaccine administration billing codes.