Reimbursement

Reimbursement A. The Division of Medicaid reimburses the lessor of the provider’s usual and customary charge or a fee from the Mississippi Medicaid fee schedule. 1. Physicians, nurse practitioners, and physician assistants: a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age and younger by VFC enrolled providers: (1) The administration fee for each single or combination vaccine administered. (2) No additional reimbursement for the cost of the vaccine. (3) An administration fee in addition to an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) visit or physician office visit only when a separately identifiable service is provided at the time of the vaccine administration. b) For the tetanus, diphtheria, and pertussis (Tdap) vaccine administered by an obstetrician to pregnant or postpartum beneficiaries eighteen (18) years or younger per ACIP’s recommendations regardless of VFC enrollment: (1) An administration fee for the Tdap combination vaccine. (2) A fee for the cost of the vaccine(s) as listed on the vaccine Medicaid fee schedule. c) For vaccines administered to beneficiaries nineteen (19) years of age and older: (1) An administration fee for each single or combination vaccine if recommended by ACIP. (2) A fee for the cost of the vaccine(s) as listed on the medical vaccine Medicaid fee schedule. 2. Pharmacy providers: a) For vaccines available through the VFC program administered to beneficiaries ten (10) to eighteen (18) years of age by VFC enrolled pharmacy providers: (1) The administration fee for each single or combination vaccine if recommended by ACIP. (2) No additional reimbursement for the cost of the vaccine(s). (3) No professional dispensing fee is paid for vaccine administration. b) For vaccines administered to beneficiaries nineteen (19) years of age and older: (1) An administration fee, the same fee as for a primary care physician (PCP) attested non-physician practitioner, for each single or combination vaccine if recommended by ACIP. (2) A fee for the cost of the vaccine(s) as listed on the pharmacy vaccine Medicaid fee schedule. The allowable ingredient cost is based on the Wholesale Acquisition Cost (WAC) + 0%. (3) No professional dispensing fee is paid for vaccine administration. c) Because vaccines are not classified as outpatient drugs: (1) Vaccines will not be included in the pharmacy prescription limit. (2) Copays will not be charged to beneficiaries. 3. A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or MSDH clinic the cost of a vaccine and vaccine administration as part of an encounter. 4. A long-term care facility for Medicaid beneficiaries when facility staff administers a vaccine: a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age or younger, the administration is reimbursed as part of the facility’s per diem rate as routine nursing services on the cost report. There is no additional reimbursement for the cost of the vaccine. b) For vaccines administered to beneficiaries nineteen (19) years of age and older: (1) The administration is reimbursed as part of the facility’s per diem rate as routine nursing services on the cost report. (2) The cost of the vaccine in the per diem rate as reported as an allowable cost on the cost report. c) The long-term care facility cannot claim vaccine costs on the cost report if an outside provider administers a vaccine. 5. An outside provider for Medicaid only beneficiaries in a long-term care facility when an outside provider administers a vaccine: a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age or younger, the administration fee. There is no additional reimbursement for the cost of the vaccine. b) For vaccines administered to beneficiaries nineteen (19) years of age and older: (1) An administration fee for each single or combination vaccine if recommended by ACIP. (2) A fee for the cost of the vaccine(s) as listed on: (a) The medical vaccine Medicaid fee schedule if billed on a medical claim, or (b) The pharmacy vaccine Medicaid fee schedule if billed on a pharmacy claim. c) The long-term care facility cannot claim these costs on the facility’s Medicaid cost report. 6. Outpatient hospitals: a) For vaccines available through the VFC program administered to beneficiaries ten (10) to eighteen (18) years of age by VFC outpatient hospital providers: (1) The administration fee for each single or combination vaccine if recommended by ACIP. (2) No additional reimbursement for the cost of the vaccine(s). b) For vaccines administered to beneficiaries nineteen (19) years of age and older: (1) An administration fee for each single or combination vaccine if recommended by ACIP. (2) A fee for the vaccine(s) as listed on the outpatient prospective payment system (OPPS) fee schedule. B. The Division of Medicaid does not reimburse for: a) The cost of a vaccine available through the VFC program administered to beneficiaries eighteen (18) years of age or younger except for the Tdap vaccine when purchased by an obstetrician who is not a VFC enrolled provider and administered to pregnant or postpartum beneficiaries. b) An administration fee or for vaccines available through the VFC program when administered by non-VFC enrolled outpatient hospital providers to beneficiaries eighteen years of age or younger. c) The administration of additional components of a combination vaccine available through the VFC program if recommended by ACIP. d) A FQHC, RHC or MSDH clinic encounter solely for the administration of vaccines. e) A vaccine administration fee to long-term care facilities, FQHCs, RHCs, and MSDH clinics. f) A long-term care facility for costs on the cost report associated with the cost of vaccines if an outside provider administers the vaccine(s). g) Vaccine(s) administered to dual-eligible beneficiaries if covered by Medicare.