Medicare Part D
MEDICARE UPDATE: Information regarding payment of administration fees for vaccines covered by Medicare Part D.
- The Tax Relief and Health Care Act (TRHCA) of 2006, enacted by the federal government on 12/20/06, required that Medicare providers be reimbursed for the administration of vaccines covered by Part D beginning 1/1/07.
- Per TRHCA, Part B covered the administration fees in 2007 only, while Part D plans are responsible for any reimbursement of these fees for 2008 and thereafter.
Effective January 1, 2008, physicians can no longer bill Medicare Part B for the administration of Medicare Part D-covered vaccines administered in the physician's office. Instead, they will need to bill the patient for the vaccine and its administration fee, unless a Part D plan is providing access to vaccines by some other process (eg, Web-based billing) that does not involve the patient paying the administration fee upfront. The patient can then submit the claim to his/her Part D plan requesting reimbursement up to the plan's allowable charge.
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0727.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5443.pdf
Vaccines and Medicare Part D1
This page is intended to help explain the vaccine reimbursement claims process for Medicare Part D. Following these steps does not guarantee that reimbursement will cover an individual patient's costs for the vaccine product and/or the administration. You should contact health plans directly to ensure that you have the most accurate and timely information on the reimbursement, patient out-of-pocket costs, and correct billing processes.
Certain adult vaccines may be eligible as a pharmacy benefit and may be reimbursed under one of two types of Medicare Part D plans:
- Prescription Drug Plans (PDPs): stand-alone prescription drug plans for patients who have Medicare fee-for-service medical coverage.
- Medicare Advantage Prescription Drug Plans (MA-PDs): medical and prescription drug benefits.
Medicare Part D plans that have added a vaccine to their formulary may require the patient to initially pay the full cost of the vaccine when the vaccine is obtained through a physician's office and then submit a paper claim requesting reimbursement from the patient's Medicare Part D plan. As noted below, some plans have special procedures for handling Part D vaccine claims, so it is important to check with each Part D plan.
For patients enrolled in Medicare Part D, following are some claims submission steps you could take when the vaccine is administered in a physician's office:
Step 1 Contact the patient's PDP or MA-PD to determine patient-specific:
- Reimbursement coverage status
- Co-pay and/or deductible information
- Claim submissions process
- Paper claim submission
- Web-based claim submission (see below)
- Any alternative claim submission procedures (if necessary)
- Share this information with the patient.
Step 2 Collect all applicable charges from the patient.
Step 3 Follow the claim submission steps outlined by the health plan.
Medicare Part D DSI eDispense Vaccine Manager is a new Web-based option for processing in-office Medicare Part D vaccine claims electronically created and operated by Dispensing Solutions, Inc. (DSI). This Web-based tool is designed to provide patient-specific vaccine coverage information and allows for online claims processing for those Medicare Part D plans that are currently participating in the eDispense network. Health care professionals must first enroll in the eDispense Vaccine Manager online in order to process claims for the Part D plans listed. For general questions or information on how to enroll see DSI's Web site at http://enroll.edispense.com. For additional questions or information, contact DSI directly at 1-866-522-3386.
Merck periodically issues eDispense Vaccine Manager Availability Reports, which list plans that Merck has been told are offering the eDispense Vaccine Manager. For the most recent report, please access the page "Reimbursement Related Resources for ZOSTAVAX" from the navigation bar on the left.
For your convenience, the MVRSC has collected information for a number of Medicare prescription drug plans (PDPs) and Medicare Advantage prescription drug (MA-PD) plans. This information may be of assistance when navigating the reimbursement process for vaccines that are covered under Medicare Part D. When available, the following information is provided for each plan:
- Link to the plan's Web site
- Plan phone number
- Link to the plan's formulary
Please note that this is not a complete list of PDP and MA-PD plans. If you do not see the plan that you are looking for on this page, please contact the plan directly.
Merck does not control the content for the sites to which these links connect and makes no representation as to the content of any non-Merck site.
Reference: 1. Dept. of Health and Human Services, Centers for Medicare & Medicaid Services. Federal Register. 2005;70(18).
PDPs
MA-PDs