MAC (Part B) Payment Requirements

10.2.5.2 - MAC (Part B) Payment Requirements (Rev. 11355; Issued:04-14-22; Effective:05-16-22; Implementation:05-16-22) Payment for Medicare covered preventive vaccines, including the recently developed COVID-19 vaccines, follows the same standard rules that are applicable to any injectable drug or biological. 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 Medicare covered preventive 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 paid at the same rate as HCPCS code 90782 on the MPFS for the year that corresponded to the date of service of the claim. For dates of service on or after March 1, 2003 through December 31, 2021, payment rates for HCPCS G0008, G0009, and G0010 were paid at the same rate as similar services on the MPFS determined through notice-and-comment rulemaking. These payment amounts were determined on an annual basis and MACs were notified accordingly. Beginning January 1, 2022, the national payment rate for HCPCS G0008, G0009, and G0010 is $30. This payment amount is adjusted based on the Geographic Practice Cost Indices used in the MPFS. Locality-adjusted payment rates for HCPCS G0008, G0009, and G0010 are available of the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Part-B- Drugs/McrPartBDrugAvgSalesPrice/VaccinesPricing Beginning January 1, 2022 and through the end of the calendar year in which the PHE for COVID- 19 ends, the national payment rate for the administration of COVID-19 vaccines is $40. This payment amount is adjusted based on the Geographic Practice Cost Indices used in the MPFS. Locality-adjusted payment rates for the administration of COVID-19 vaccines are available of the CMS website: https://www.cms.gov/medicare/medicare-part-b-drug-average-sales-price/covid-19- vaccines-and-monoclonal-antibodies Effective January 1 of the year following the year in which the PHE for COVID-19 ends, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines. 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. MACs (Part B) may not apply the limiting charge provision for pneumococcal, influenza virus , hepatitis B, or COVID-19 vaccines and their administration in accordance with §§1833(a)(1) and 1833(a)(10)(A) of the Social Security Act (the Act.) The vaccine and administration of the pneumococcal and influenza virus, and COVID-19 vaccine is covered in §1861(s)(10)(A) of the Act; §1861(s)(10)(B) includes the hepatitis B vaccine and administration 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, influenza virus, and COVID-19 vaccines administered to Medicare beneficiaries when services are rendered free of charge to non-Medicare beneficiaries. Government entities may NOT bill Medicare for vaccine products during a public health emergency when vaccines are provided at no charge to Medicare and non-Medicare beneficiaries.