Provider Notice issued 05/19/09

Change in Vaccines for Children (VFC) Plus Coverage for 19 and 20 year olds

The IDPH notification stated:

"Illinois VFC Program has received notice from the CDC's National Center for Immunization and Respiratory Diseases that these purchases cannot be covered under current federal vaccine contracts held with manufacturers. Therefore, you must immediately discontinue using vaccine obtained from the VFC Program for 19 and 20 year olds who are enrolled in Medicaid."

Previously, all HFS enrolled participants ages 19 and 20 years were covered through an interagency agreement between HFS and IDPH. Under that agreement, VFC enrolled providers received vaccines for 19 and 20 year olds at no cost from IDPH or the Chicago Department of Public Health (CDPH) through the VFC Plus program and reimbursement for the vaccine was not available through HFS. 

Since IDPH can no longer cover the cost of vaccines for this age cohort, HFS will reimburse providers for vaccinations provided to 19 and 20 year olds through fee-for-service using the Current Procedural Terminology (CPT) code corresponding to the vaccine provided. Payment will be made for the vaccine according to the rates posted in the State Max. column on the Practitioner Fee Schedule or the lesser of charges. Reimbursement for the practice expense of administering the injection is covered in the office visit code when the client sees a practitioner. If the client comes in solely for the injection, bill the vaccine code and 99211 to cover the practice expense.    

Providers giving immunizations to participants enrolled in Managed Care Organizations (MCOs) should now bill the MCO for vaccines provided to this population. Providers should continue to submit encounter data to the MCO for these services.  

Federally Qualified Health Centers (FQHC) and Rural Health Centers (RHC) will receive their established encounter rate as opposed to fee-for-service for each vaccine rendered to enrollees who are 19 to 20 years of age. As currently required, the detail regarding the specific vaccination defined by the CPT code must be reported on the encounter billing form. This will ensure that an accurate immunization history is received and recorded by HFS and is available to the child's "medical home" provider, parent/caretaker, relative or guardian.  This record will also enable parents to provide accurate information on immunizations to their child's school as required by Illinois law.

Please note, HFS pays for medically necessary adult immunizations as determined by the provider. Centers for Disease Control and Prevention (CDC) guidelines should be followed. Adult immunizations are a critical component of preventive and primary care. Common examples of such immunizations are influenza vaccine, pneumococcal vaccine, tetanus and diphtheria toxoids vaccine (Td), tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap). Providers should bill using the appropriate CPT code for the individual service.

For information about the VFC Plus Program, please contact the Illinois Department of Public Health (IDPH) at 1-800-526-4372, or visit the IDPH Web site. Providers in Chicago should contact the Chicago Department of Public Health (CDPH) at 312-746-6050.

For information about recommended vaccines for children, view the Centers for Disease Control Web site or the Illinois Chapter, American Academy of Pediatrics Web site.

If you have questions regarding this notice, please contact the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator
Division of Medical Programs