State Vaccine Programs (SVPs) are programs run by state entities such as State Health Departments or other state agents to promote vaccination of children and sometimes adults in the state. SVPs don’t administer vaccines—they supply the vaccines at no cost to providers who administer the vaccines within the state and bill insured patients’ health insurers.

A policy change (TRICARE Policy Manual, Chapter 11, Section 9.2) allows SVPs to be reimbursed:

• For TRICARE-covered vaccines they supply to providers,
• That are given to TRICARE beneficiaries, and
• If they become certified as TRICARE-authorized providers

Becoming TRICARE-Authorized

SVPs can be certified as TRICARE-authorized providers if they:

• Hold a valid National Provider Identification Number
• Enter into a Participation Agreement with TRICARE (TRICARE Policy Manual, Chapter 11, Section 12.3)
• Agree to accept the lesser of the TRICARE allowed amount or billed charge as payment in full for the vaccines supplied
• Agree to not Balance BillThe practice of a provider billing a beneficiary the difference between the TRICARE allowed amount and the billed charges on a claim. Participating providers and network providers may not collect from all sources an amount which exceeds the TRICARE allowed amount. Non-participating providers may not collect an amount which exceeds the balance billing limit (115% of the allowed charge). If the billed charge is less than the balance billing limit, then the billed charge is the maximum amount that can be collected by the non-participating provider. (See the TRICARE Reimbursement Manual (TRM), Chapter 3, Section 1.)balance bill the beneficiary

The managed care support contractors are the certifying authorities for SVPs located in their regions. .

Reimbursement of Supplied Vaccines

TRICARE-authorized SVPs can only be reimbursed for the supplied vaccines once administered. TRICARE is able to reimburse only for covered services and supplies rendered to a TRICARE beneficiary. As a result, TIRCARE is unable to “prefund” vaccines that may subsequently be administered to TRICARE beneficiaries.  The federal dollars expended under the TRICARE program must be accounted for an claims-based payments allow for such an accounting.  

• The vaccines must be covered by TRICARE and used to immunize TRICARE beneficiaries.
• Appropriate claim forms for covered vaccines would need to be properly filed for each beneficiary receiving a vaccine.
• Any other charges such as professional or administrative fees aren’t reimbursable, as these may be paid to the provider administering the vaccine. 

Reimbursement can only be made for dates of service that fall on or after the date that the required participation agreement is signed and the SVP is certified as an authorized provider.