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The National Vaccine Advisory Committee (NVAC)

Date version:  July 17, 2009

Draft 2009-H1N1 Influenza Vaccination Program Financing Policy Recommendations

For consideration by NVAC July 27, 2009

The recommendations proposed below are based on the principles outlined in the NVAC vaccine financing recommendations of September 2008 (available at: www.hhs.gov/nvpo/nvac/cavfrecommendationssept08.html) and detailed in “Assuring Vaccination of Children and Adolescents without Financial Barriers: Recommendations from the National Vaccine Advisory Committee.”

ASSUMPTIONS:  The federal government will purchase all doses of 2009-H1N1 influenza vaccine manufactured for distribution in the United States, and will work through each state to distribute vaccine to the public and private sectors. The federal government will provide funds to states to help implement the vaccination program, including funds to cover the cost of vaccine administration in clinics organized by the public sector.

Recommendation #1 – first dollar coverage for administration of 2009-H1N1 influenza vaccine
All public and private health insurance plans should voluntarily provide first-dollar coverage (i.e., no deductibles or co-pays) for the administration of 2009-H1N1 influenza vaccine administered in any setting (e.g., pharmacies, work sites, mass vaccination clinics in alternate venues).  All government sponsored programs providing healthcare for uniquely defined populations (e.g. Bureau of Prisons, Department of Defense, Indian Health Service, Department of Veterans Affairs) should voluntarily provide first-dollar coverage for administration of 2009-H1N1 influenza vaccine to their beneficiaries in venues where those beneficiaries are traditionally served.

Recommendation #2 – reimbursement rates for administration of 2009-H1N1 influenza vaccine
All public and private health insurance plans should reimburse providers for administration of 2009-H1N1 influenza vaccine to, at a minimum, the nationally established Medicare payment rate, including geographic adjustment for each Medicare payment locality. Reimbursements should factor in all costs associated with administration of 2009-H1N1 influenza vaccine (including, for example, vaccine handling, storage, labor, patient or parental education, and record keeping).

Recommendation #3 – reimbursement
CMS should establish a national policy whereby the federal government provides 100% reimbursement, at the nationally established Medicare payment rate, for the administration of 2009-H1N1 influenza vaccine to Medicaid and SCHIP beneficiaries and to other non-Medicaid Vaccines for Children program (VFC)-eligible children served by VFC providers.

Recommendation #4 – community vaccinators
Community vaccinators (including pharmacies, urgent care clinics, and retail-based clinics) and national, regional and local insurance plans should work together to develop formalized relationships allowing community vaccinators to bill these insurance plans for administration of 2009-H1N1 influenza vaccine to plan beneficiaries.

Recommendation #5 – community vaccinators
CMS should establish a national policy whereby community vaccinators are permitted to bill Medicaid – including via roster billing – for administration of 2009-H1N1 influenza vaccine to Medicaid beneficiaries outside the provider office, without requiring each state to obtain a Section 1115 Medicaid State Waiver.a

Recommendation #6 – funding to states
Funding to support mass immunization campaigns for 2009-H1N1 influenza managed by state and local health departments should be allocated to states from the unobligated contingency funds authorized in the Supplemental Appropriations Act of 2009b. ($335M in funding for state and local immunization planning was announced on July 17, 2009; assessment of funding needs for states should be ongoing.)

 

NVAC encourages the Financing Subgroup of CDC’s H1N1 Vaccine Implementation Steering Committee to continue pursuing its full scope of work, with particular attention to developing a policy on reimbursement of 2009-H1N1 influenza vaccine administration for uninsured adults. NVAC requests an update on additional issues related to financing the administration of 2009-H1N1 influenza vaccine at its August 24, 2009 meeting.

a Section 1115 of the Social Security Act provides the Secretary of Health and Human Services broad authority to authorize experimental, pilot, or demonstration projects likely to assist in promoting the objectives of the Medicaid statue.  Flexibility under Section 1115 is sufficiently broad to allow states to test substantially new ideas of policy merit.  Waiving the state by state requirement to file an exemption to Medicaid allows community immunizers the ability to roster bill for Medicaid beneficiaries not already covered by the Vaccines for Children Program (i.e. adults).

b HR 2346 Supplemental Appropriations Act 2009 was signed into law on June 24, 2009.