When you are setting up an immunization program in your practice, it is important to investigate third party coverage for the costs and administration of the immunizations you plan to offer. Patients may be enrolled in employer-provided health insurance plans, or private insurance plans that have limited vaccine reimbursements for physicians. It is important to communicate with the insurance carriers most often used by the patients in your practice to verify vaccine coverage and administration. Reimbursement varies by insurance carrier. Tracking payment of insurance claims is an invaluable tool in assessing coverage for immunization services. Correct coding helps ensure that a practice receives payment for vaccines given to patients. See the coding page for more detailed information about immunization coding.
Under the Affordable Care Act (ACA) vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), are required to be provided with no-cost sharing (i.e. no co-pay) for children, adolescents, and adults. Check the list of vaccines covered for more information about the ACA.
Federal regulations require all CDC recommended vaccines and routine immunization coverage of persons up to 21 years of age covered under the Medicaid program and the Children’s Health Insurance Program (CHIP). This coverage is for low-income families and which families are covered varies on a state-by-state basis.
Medicare Part B, the federal program for those over 65 or disabled, currently covers the administration of three vaccines: influenza (once per influenza season), pneumococcal polysaccharide and booster for high risk persons (once per lifetime), and hepatitis B. Medicare Part D does not cover other immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition (e.g. tetanus, rabies exposure). Additional information about the Medicare Part B/Part D coverage differences can be found by clicking the following links.
Your practice may be able to obtain free or discounted vaccines to reduce initial and overhead costs. Vaccines for Children (VFC) is a federal program that provides free vaccine for all persons from birth through 18 years (until their 19th birthday) who meet VFC criteria. Contact the VFC coordinator at your local and state health department for eligibility requirements for patients in this age range. The VFC website contains information addressed to providers. As an added benefit, the state immunization program staff may be able to provide on-site assistance setting up your office immunization program. Another useful strategy is to join with other providers for bulk or group purchasing which generally lowers the per-unit costs of vaccines and supplies.
While there are many costs associated with purchasing and administering vaccines, there are ways for ob-gyn offices to manage these costs in order to cover overhead. For additional information about Group Purchasing Organizations, Physician Buying Groups, and “Questions to Ask” if you are considering joining a GPO or PBG, visit the American Academy of Pediatrics page on the topic.
For updated vaccine costs, visit CDC’s vaccine price list.