VFC Vaccine Administration Fees

A: Section 1928(c) (2) (C) (ii) of the Social Security Act (42 U.S.C. 1396s(c) (2) (C) (ii)) states: "The provider may impose a fee for the administration of a qualified pediatric vaccine so long as the fee in the case of a federally vaccine-eligible child does not exceed the costs of such administration (as determined by the Secretary based on actual regional costs for such administration)."

Section 1928(c) (2) (C) (iii) of the Social Security Act (42 U.S.C. 1396s(c) (2) (C) (iii)) further provides that: "The provider will not deny administration of a qualified pediatric vaccine to a vaccine-eligible child due to the inability of the child's parent to pay an administration fee."

The Health Care Financing Administration (HCFA), now the Centers for Medicare and Medicaid Services (CMS), published a notice of the federal regional administration fee caps in the Federal Register on October 3, 1994 (59 FR 50235). The notice also indicated that state Medicaid programs could establish lower administration fees for VFC vaccination of Medicaid children. Except in the case of an inability to pay, the notice further stated that VFC providers can charge non-Medicaid federally vaccine-eligible children (i.e., uninsured, American Indian/Alaska Natives, and when administered by an FQHC or RHC, underinsured children) up to but not more than the maximum regional administration charge (if that charge reflects the provider's cost of administration) regardless of whether the state has established a lower administration fee under the Medicaid program.

The administration fee caps do not apply to vaccination of state vaccine-eligible children. The VFC program does not have any authority over administration fees charged to state vaccine-eligible children or privately insured children.

For example:
State A's Medicaid Agency has set the state Medicaid vaccine administration reimbursement at $10.00. The state's regional administration fee cap is $15.00. A VFC-enrolled provider can expect to receive $10.00 for the administration of a vaccine to a VFC-eligible child enrolled in Medicaid. The VFC-enrolled provider can charge a maximum of $15.00 to a VFC-eligible child NOT enrolled in Medicaid. The VFC program does not regulate administration fees charged to private pay or privately insured patients.

A: The state Medicaid agency should be billed for the administration fee for Medicaid-eligible VFC children immunized by a Medicaid-enrolled VFC provider. State Medicaid agencies establish their own policies and administration fees that may be lower than the regional maximum charges established in 1994. For Medicaid VFC-eligible children, the state Medicaid agency determines and CMS approves the reimbursable amount for their fee-for-service and managed care enrolled recipients. If the provider bills Medicaid the regional maximum charge instead of the Medicaid agency’s allowable rate the provider will be reimbursed only the allowable rate and not the amount billed. The difference between the allowable rate and the amount billed cannot be collected from the parents of the child.

A: The VFC administration fee caps only apply to VFC eligible children and do not apply to privately insured children.

A: State Medicaid agencies, through processes that vary from state to state, may raise the VFC administration fees payable to Medicaid providers for vaccinating Medicaid eligible children up to the regional fee cap that was established for each state in 1994. Should a state consider its CMS-imposed cap to be too low, CMS and CDC should be contacted to discuss potential revision of the fee cap. Because so few state Medicaid agencies are reimbursing at the maximum regional charge, the current fee structure will remain in effect until further notice.

A: The October 1994 Federal Register notice gives universal purchase states (states in which the vaccines are purchased by the state for all children in the state) the right to develop administration fees that differ from those established by CMS, provided they are reasonable. Therefore, universal purchase states are provided the flexibility to accept the maximum charges established by the Secretary or develop their own maximum charges. The maximum charges must be developed utilizing a reasonable methodology based on VFC section 1928(c)(2)(C)(ii) of the Social Security Act. The amount of the cap (maximum fee) is not required to be set in state law. However, the authority to set an amount must be based in state law. In either case, CMS gives state Medicaid agencies the option to establish and apply vaccine administration fees that are lower than the specified maximum regional charges if they provide assurances that Medicaid children have access to immunizations to the same extent as the general population.

A: It is necessary to be a Medicaid provider in order to receive payment from Medicaid for vaccine administration services provided to Medicaid-eligible children. Providers should consult the state Medicaid agency about the procedures necessary to become a Medicaid provider.

A: There is nothing in the VFC legislation that mandates a posted sign in provider offices. Other means of communication may be used.

A: Section 1928 (c)(2)(C)(iii) of the Social Security Act states, "The provider will not deny administration of a qualified pediatric vaccine to a vaccine-eligible child due to the inability of the child’s parents to pay an administration fee." The statute further notes at Section 1928(c)(2)(C)(i) that "A program-registered provider is not required under this section to administer such a vaccine to each child for whom an immunization with the vaccine is sought from the provider." CDC interprets this to mean that private VFC providers, unless otherwise required by another statute, do not have to honor vaccine requests by VFC-eligible children who "walk in" for immunizations only and are not established patients in the practice. For established VFC-eligible patients and other VFC-eligible patients that the provider chooses to immunize, VFC immunization cannot be denied due to the inability to pay an administration fee.

A: The two new CPT codes are:
90460 – Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component, 90461 – Each additional vaccine/toxoid component.

These codes replace 90465, 90466, 90467, and 90468.

Every vaccine administered has exactly one first component, and many vaccines have second and subsequent components (e.g., MMR, DTaP, and DTaP/IPV).

In the VFC program, the regional vaccine administration fee cap rates were established on a per-vaccine basis, not a per-antigen or per-component basis. Under current interpretation of CMS policy, the administration fee for the VFC program will continue to be based on a per-vaccine basis and not on a per-antigen or per-component basis. CMS is looking closely at the VFC administration fee cap to ensure that it keeps up to date with changes in underlying costs of providing vaccines and with medical practice. CMS anticipates updating the fee cap in the near future and is also examining the larger reimbursement structure of the VFC program. In the meantime, State Medicaid agencies can increase the amount they pay providers up to their regional cap by submitting a State Plan Amendment, as most States are currently paying providers rates that are below their State caps. In addition, States can choose to establish different rates, up to their regional caps, for vaccines with multiple antigens and for those that have only a single component.

VFC-enrolled providers may not charge a vaccine administration fee to VFC-entitled children that exceed the regional administration fee cap per dose of vaccine.

A: Providers are encouraged to use the new code 90460 for the administration of a vaccine under the VFC program. If code 90461 is used for a vaccine with multiple antigens or components, it should be given a $0 value for a child covered under the VFC program. This applies to both Medicaid-enrolled VFC-entitled children as well as non-Medicaid-enrolled VFC-entitled children (i.e., uninsured, underinsured, and American Indian or Alaska Native children not enrolled in Medicaid).

Please define the term "waive" in the context of this section of Module 3 (pages 8-9) of the VFC Operations Guide (February 2011):

6. Not deny administration of a federally purchased vaccine to an established patient because the child's parent/guardian/individual of record is unable to pay the administration fee.

Provider Education Goals for this requirement:

By the end of the enrollment or education session the provider and staff will understand

• This requirement applies to VFC vaccines as well as any other vaccines purchased through the CDC federal contracts when the eligible child's family/guardian is unable to pay the administration fee;
• The only fee that must be waived is the administration fee. Other visit or office fees may be charged as applicable.
  Q&A added July 2011

  The term "waive" in this context is based on the first entry of "waive" as defined in the online version of Merriam-Webster dictionary #1). 1 give up, forsake.

  So, if the parent cannot pay the administration fee for a VFC vaccine, the provider must give up or forsake the VFC administration fee.

A: There are no restrictions against sending a bill for the vaccine administration fee after the point of service. However, the provider cannot send the bill for the vaccine administration fee to collections if the parent cannot afford to pay (i.e., if the parent does not pay the bill). The provider can send the office visit fee or any other visit fee (e.g., labs) to collections if unpaid, but not the vaccine administration fee. The federal requirement restricts the provider from seeking payment if the parent cannot afford it. But this is not a restriction from sending a statement or bill after the point of service. If the parent cannot pay the administration fee for a VFC vaccine, the provider must waive it.