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Provider Notice Issued 08/12/2019
Date: August 12, 2019
To: Physicians; Advanced Practice Nurses; Local Health Departments; School-based Linked Health Centers; Encounter Rate Clinics; Federally Qualified Health Centers; and Rural Health Clinics
Re: Changes to Vaccination Billing Requirements Effective with Dates of Service Beginning September 1, 2019
The Department is pleased to announce that upcoming changes to the Vaccines for Children (VFC) Program will allow providers to obtain vaccines for additional children covered under the Department’s Medical Programs.
The Department will soon be changing its vaccine reimbursement policy for children under the age of 19. The Department will require providers to use vaccine acquired through the VFC Program for all children enrolled in HFS’ medical programs, including Title XXI (Children’s Health Insurance Program, or CHIP) and state-only funded children ages 0 through 18. Providers will no longer be reimbursed for the cost of privately purchased vaccines for CHIP and state-only funded children if the vaccine is available through the VFC program. There is no change in coverage policy for Title XIX (Medicaid Program) children.
As of July 1, 2019:
Vaccines for children with CHIP or state-only funded coverage can be ordered through the Vaccines for Children (VFC) program administered by the Illinois Department of Public Health (IDPH). The IDPH notified providers of this change on July 1 via a release in its Siren alert system. The notification is also identified in I-CARE, Illinois’ immunization registry maintained by the IDPH.
For Dates of Service Prior to September 1, 2019:
Providers must continue to use private stock to vaccinate CHIP and state-funded children. For practitioners, local health departments, and school-based linked health centers, reimbursement will be the lesser of charges or the rate shown in the Practitioner Fee Schedule State Max column plus the Unit Price of $6.40. Reimbursement for Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), and Encounter Rate Clinics (ERCs) is based on the State Max column shown in the Practitioner Fee Schedule. These provider types do not receive the additional $6.40 for the administrative cost of acquiring the vaccine.
For Dates of Service Beginning September 1, 2019:
The Department will reimburse practitioners, local health departments, and school-based linked health centers $6.40 for the administrative cost of acquiring the free vaccine through the VFC program for all children covered through the Department’s medical programs regardless of title eligibility. FQHCs, RHCs and ERCs do not receive the additional $6.40 for the administrative cost of acquiring the vaccine.
When submitting a claim for the administrative cost of a VFC-acquired vaccine, all providers must bill using the CPT code for the specific vaccine product.
Vaccines Unavailable through the VFC Program:
For private stock vaccines that have never been available through VFC and administered to any child regardless of eligibility type, the Department will continue to reimburse the medically necessary vaccine product at the lesser of charges or the rate shown in the State Max column in the Practitioner Fee Schedule. Providers should bill the vaccine code only. The administrative cost of obtaining the vaccine is not reimbursable.
Providers should continue to verify eligibility through the MEDI system prior to rendering services. MEDI will also verify if the child has fee-for-service coverage or is covered under a HealthChoice Illinois managed care plan.
Vaccinations are an open access medical service. Managed care patients do not need a referral to receive vaccinations, even if the provider administering the vaccine is not in-network. A clinic, local health department, or another practitioner administering the vaccination can receive reimbursement.
The Department encourages providers to assess and update a child’s vaccination status at every sick and well visit in the medical home. Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Doug Elwell
Medicaid Director