Medicare and Vaccine Billing: What You Need to Know

Pharmacies need to be aware of the risks of billing claims [to Medicare B/D] for patients under a Medicare Part A stay. Recently, a member asked the question of vaccine coverage for patients on a Medicare A stay, and how the billing should be done. Pharmacies can refer to Medicare Claims Processing Manual, Chapter 6  for guidance on the appropriate billing.

Let us first break down the Medicare coverage for vaccines:

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Medicare Part B includes coverage for four preventive vaccines. These are typically vaccines that protect against diseases that are more common among older adults and those with chronic conditions. Here are the vaccines covered under Medicare Part B:

  • Influenza Vaccine: The seasonal flu shot once per annual flu season (August 1-July 31 of the following year).
  • COVID-19 Vaccine: The vaccines and boosters as deemed necessary.
  • Pneumococcal Vaccine: Refer to the CMS Medicare Learning Network (MLN) for recent revisions on coverage and frequency.
  • Hepatitis B Vaccine: Coverage for patients considered high risk for the disease (i.e. with end-stage renal disease (ESRD) or certain other conditions).

Medicare Part D, which covers prescription drugs, may include vaccines that are not covered under Part B. This includes:

  • Shingles Vaccine: specifically, the newer recombinant zoster vaccine (Shingrix).
  • Respiratory Syncytial Virus (RSV) Vaccine
  • Other Vaccines: Some vaccines administered in a pharmacy setting or are considered prescription vaccines can also be covered under Part D. Pharmacies should check with plan, as coverage may vary between plans.

Now the question of how to bill Medicare for vaccines when the patient is under a Part A stay? If the patient is receiving a vaccine:

  • Covered Under Part B
    • The facility is required to bill for that vaccine and the administration pursuant to the Balance Budget Act of 1997 (see Consolidated Billing)
      • The enforcement discretion for consolidated billing during the Public Health Emergency expired 7/1/2023
  • Covered Under Part D
    • The pharmacy may bill for that vaccine and the administration

PAAS Tips:

  • Pharmacies servicing skilled nursing facilities, assisted living facilities and group homes must stay in constant communication with these facilities to stay on top of the patient’s current Medicare coverage
  • Prior to any vaccine clinic, verify all patients Medicare status for the day of administration
  • All vaccines must bill billed for the date the vaccine is administered
  • For further information, see the following Newsline articles:

Dana Westberg, CPhT
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