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Provider Notice issued 01/31/2024
| To: | Enrolled Physicians, Physician Assistants (PAs), Advanced Practice Registered Nurses (APRNs), Local Health Departments (LHDs), Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs), Encounter Rate Clinics (ERCs), Home Health Agencies, School Based/Linked Health Centers (SBLHCs), and Pharmacies |
| Date: | January 31, 2024 |
| Re: | Proposed Rate Changes for Administration of COVID-19 Vaccine |
The Illinois Department of Healthcare and Family Services (HFS) has submitted a State Plan Amendment (SPA) to the federal Centers for Medicare & Medicaid Services (CMS) to change the methodology by which HFS will reimburse providers for costs associated with the administration of the COVID-19 vaccine.
These changes are intended to better align reimbursement to providers for the administration of the COVID-19 vaccine with HFS’ reimbursement methodologies for other vaccines. The proposed changes are effective for dates of service on or after January 1, 2024.
By Public Notice, the Department is proposing the following reimbursement updates related to the administration of COVID-19 vaccines:
Provided to children eligible under the Vaccine for Children (VCP) program:
Ø Services performed by physicians, PAs, APRNs, LHD, SBLHCs, FQHCs, RHCs or ERCs - Providers will be reimbursed a vaccine administration fee of $16.71.
Provided to Other Medicaid customers:
Ø Services performed by a physician, PA or APRN - Reimbursement is included in the office visit, consistent with HFS billing policies.
Ø Services performed in an FQHC, RHC, or ERC setting - Providers will be reimbursed a professional dispensing fee of $8.85 and a vaccine administration fee of $6.40. The professional dispensing and vaccine administration fees are separate from any encounter payment the FQHC, RHC, or ERC may receive.
Provided in a pharmacy:
Ø All pharmacies will be reimbursed a $6.40 vaccine administration fee and a professional dispensing fee of $8.85, except Critical Access Pharmacies will be reimbursed a professional dispensing fee of $15.55.
Please note: The rate for the COVID-19 vaccine for all provider types will continue to be set at the Medicare rate.
Until the rate changes are federally approved, all fee-for-service (FFS) practitioner claims with dates of service on and after January 1, 2024, that contain vaccine administration codes will be placed on hold. At the time federal approval is received, the claims will be released and reimbursed at the correct rates.
For FFS pharmacy claims with dates of service on and after January 1, 2024, pharmacies should continue to provide the vaccine and either:
1) Hold the claims until the administration fee is approved and then bill, or
2) Bill with no vaccine administration code and receive only the professional dispensing fee and reimbursement for the vaccine cost. Void/rebill the claims at a future date to include the appropriate approved administration fee for full payment.
Providers will be notified at the time CMS makes the SPA determination.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565 or the applicable managed care plan.
Kelly Cunningham, Administrator
Division of Medical Programs