(A) General information.
(1) Immunizations are usually given in conjunction with a medical service. When an immunization is the only service performed, the lowest level of office visit (evaluation and management code) may be billed in addition to the immunization procedure code without using modifier 25. Immunization procedure codes include the supply of materials and the provision of the vaccine except for vaccinations covered by the federal vaccines for children (VFC) program. The codes used in this rule are current procedural terminology (CPT) codes. CPT, as used in this rule, is defined in rule 5101:3-1-19.3 of the Administrative Code.
(2) Designated free vaccines.
(a) For dates of service on or after the effective date of this rule, pending the availability of the vaccine, the term "designated free vaccine(s)" shall mean all of the immunizations for individuals eighteen years or younger covered under the federal VFC program.
(b) Providers of medicaid services obtain designated free vaccines from the Ohio department of health (ODH) free of charge for the immunization of eligible medicaid recipients. Information regarding participation in the designated free vaccine program is detailed in paragraph (D) of this rule.
Codes designated as free vaccines are listed in appendix A to this rule.
(3) The term "nondesignated vaccines" shall mean all covered active and passive immunizations not designated as free vaccines in paragraph (A)(2) of this rule that are for individuals nineteen years of age or older.
(4) Under the medicaid program, "provision of the vaccine" or "provided the vaccine" means the provider either received the designated free vaccines from ODH or purchased, from the manufacturers, vaccines that are not designated as free vaccines. The provision of the vaccine is the hospital's responsibility when immunizations are provided in a hospital setting.
(1) The immunizations specified in appendix A and appendix B to this rule are covered by the department when administered in accordance with the recommendations listed in paragraph (B)(1)(c) of this rule. Additional coverage limitations are specified in paragraphs (B)(2) to (B)(6) of this rule.
(a) All designated free vaccines specified in paragraph (A)(2) of this rule.
(b) Nondesignated vaccines for individuals nineteen years of age or older listed in appendix B to this rule.
(c) National immunization recommendations referenced in paragraph (B)(1) of this rule can be found at the following web sites:
(i) Centers for disease control (CDC) immunization recommendations can be found at http://www.cdc.gov/vaccines/ 01/04/2010;
(ii) American academy of pediatrics (AAP) immunization recommendations can be found at http://www.cispimmunize.org 08/25/2009; and
(iii) Advisory committee on immunization practices (ACIP) recommendations can be found at http://www.immunize.org/acip 04/28/2010.
(2) Hepatitis B vaccines (HBV).
(a) Regardless of the formulation, hepatitis B vaccines administered to individuals under the age of nineteen, to include those who require dialysis or are immunosuppressed, are available free from ODH and must be billed using code 90744.
(b) Hepatitis B vaccines administered to individuals nineteen years or older must be billed using code 90746.
(3) Active immunizations identified with an asterisk (*) in appendix A to this rule are available and covered only under special circumstances as determined and approved, on the basis of medical necessity, by ODH.
(4) Active immunizations identified with a double asterisk (**) in the appendices to this rule are covered on a case-by-case basis and only if determined by ODJFS as medically necessary.
(5) The quadrivalent vaccine (CPT code 90649) for the human papilloma virus (HPV) is covered for males and females ages nine through twenty-six who are eligible only through the limited family planning benefit. For those otherwise eligible, this vaccine is covered for males and females ages nine through twenty-one. The HPV bivalent vaccine (CPT code 90650) is covered for females ages nine through twenty-six who are eligible only through the limited family planning benefit. For those otherwise eligible, this vaccine is covered for females ages nine through twenty-one. This vaccine is not covered for males.
(6) Preservative free influenza vaccine.
For dates of service on and after September 1, 2005, the department will cover the preservative free influenza vaccine, codes 90655 and 90656, through the federal VFC program. The department will reimburse for the administration fee for this vaccine as described in paragraph (G)(2) of this rule.
(C) Immune globulins.
(1) Immune globulins are covered when it is medically necessary to provide passive immunity to an individual who is immunosuppressed, has an acquired or congenital immunodeficiency, is at risk of Rho(D) isoimmunization, or is in immediate danger of contracting hepatitis B, tetanus, or rabies through direct contamination with blood, saliva or other body fluids, through an open wound, bite, puncture, or mucous membrane. Immune globulins would include nonspecific human serum globulin and specific hyperimmune globulins such as hepatitis B, measles, pertussis, rabies, Rho(D), tetanus, vaccinia, and varicella-zoster.
(2) When immune globulins are administered through the intramuscular or subcutaneous route use immune globulin codes in the range of 90281 through 90396. Otherwise, use an injection code as listed in appendix DD to rule 5101:3-1-60 of the Administrative Code. The following provisions apply to specific types of immune globulin services effective for services provided on and after January 1, 2003:
(a) For botulinum antitoxin, bill code 90287 if the antitoxin is for non-cosmetic purposes. For intravenous botulism immune globulin, bill the appropriate injection code as listed in appendix DD to rule 5101:3-1-60 of the Administrative Code.
(b) For cytomegalovirus immune globulin, human for intravenous use, bill 90291 per ml in the unit field.
(c) For respiratory syncytial virus immune globulin for intra-muscular use, bill 90378. For respiratory syncytial virus immune globulin for intravenous use, bill the appropriate injection code as listed in appendix DD to rule 5101:3-1-60 of the Administrative Code.
(d) For Rho(D) immune globulin codes 90384 and 90385, bill one vial in the units field for each dose provided. For Rho(D) for intravenous use, bill the appropriate injection code.
(3) Effective January 1, 2003, code 90281 will be covered by the department when billed per ml. Code 90399 will not be recognized by the department when billing immune globulins.
(D) Participation in the free vaccine program for immunizations.
(1) ODH is the agency responsible for the enrollment of providers and the purchase, provision and distribution of designated free vaccines under the VFC program. Therefore, Ohio medicaid is not involved in the purchase, the provision, nor the distribution of the designated free vaccines available for medicaid patients.
(2) To receive designated free vaccines for the immunization of their medicaid patients, medicaid providers must take the following steps:
(a) Register with ODH;
(b) Agree to the terms in the ODH provider agreement;
(c) Provide a medical license or terminal distributor license;
(d) Demonstrate the ability to appropriately store and monitor the vaccine (as verified by ODH or the local health district); and
(e) Submit an order for the vaccine.
(1) Providers may order the designated free vaccines listed in appendix A to this rule for all of their medicaid patients (both fee-for-service and managed care plan) directly from ODH by completing a vaccine order form and submitting it to ODH.
(2) Medicaid vaccine orders may be combined and submitted with the provider's orders for their other federal VFC program-eligible patients (i.e., uninsured, American Indian and native Alaskan patients).
(3) Further information regarding the ordering and receipt of free pandemic influenza virus vaccine can be found at https://h1n1vaccine.odh.ohio.gov [File Link Not Available] 10/01/2009.
(1) Designated free vaccines/ federal VFC program covered vaccines.
Medicaid providers are required:
(a) To bill medicaid for the administration of the designated free vaccines provided to their fee-for-service medicaid patients using the appropriate codes; and
(b) To report to medicaid contracting managed care plans (MCPs), as instructed by those managed care plans, the number of immunizations administered to their MCP-enrolled medicaid patients.
(2) Nondesignated vaccines.
(a) Providers who provided the vaccines identified in appendix B to this rule may be reimbursed the medicaid maximum for each immunization provided. For reimbursement the provider must bill the corresponding code for the immunization.
(b) Nondesignated vaccines identified in appendix B to this rule by a double asterisk (**) must be billed by report with the medical indications for coverage.
(1) The medicaid maximum for each vaccine is not to exceed the medicare maximum for the vaccine. The department will pay the lesser of the provider's billed charge or the medicaid maximum in the appendices to this rule.
(2) The medicaid maximum for each designated free vaccine code is five dollars for dates of services on and after October 1, 1994 through June 30, 2008. Effective for dates of service on and after July 1, 2008, the medicaid maximum is ten dollars. As long as the designated free vaccines are available free through an interagency agreement between the department and ODH and/or the federal VFC program, the provider's lowest acquisition cost for the designated free vaccines is zero and reimbursement for these vaccines will be limited to the maximum set forth in this paragraph.
(3) Effective for dates of service on and after July 25, 2007, the codes 90633, 90634, 90645, 90646, 90647, 90648, 90656, 90658, 90660, 90703, 90707, 90710, 90714, 90715, 90716, 90718, 90732, 90733, and 90734 for individuals eighteen years or younger will be covered under the federal VFC program and will be reimbursed as described in paragraph (G)(2) of this rule. For adults over eighteen years of age, the codes will be reimbursed at the lesser of the provider's billed charge or the medicaid maximum as described in paragraph (G)(1) of this rule.
(4) Immunizations are reimbursable as a physician or clinic service only if the immunization was provided in a nonhospital setting.
(5) Immunizations administered in a hospital setting are reimbursable only to a hospital billing on an institutional claim form/transaction.
(6) Reimbursement is not available for the cost of designated free vaccines obtained from a source other than ODH.
(7) Only a pharmacy participating in the medicaid program can be reimbursed for immunizations prescribed for residents of a long-term care facility (LTCF), nursing facility (NF) or intermediate care facility for the mentally retarded (ICF/MR), and subsequently administered by LTCF staff.
R.C. 119.032 review dates: 09/01/2016
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 4/1/77, 12/21/77, 12/30/77, 1/8/79, 2/1/80, 9/20/84 (Emer), 12/17/84, 5/19/86, 7/1/87, 4/1/88, 9/1/89, 3/19/92, 12/30/92 (Emer), 4/1/93, 12/30/93 (Emer), 3/31/94, 9/30/94 (Emer), 12/30/94, 12/29/95 (Emer), 3/21/96, 12/31/96 (Emer), 3/22/97, 8/1/97, 12/31/97 (Emer), 3/19/98, 12/31/98 (Emer), 3/31/99, 3/20/00, 12/29/00 (Emer), 3/30/01, 1/1/03, 4/14/03, 1/2/04 (Emer), 4/1/04, 10/1/04, 9/1/05, 12/30/05 (Emer), 3/27/06, 7/15/06, 1/1/07, 7/25/07, 7/1/08, 11/13/08, 10/1/09 (Emer), 12/29/09, 3/31/10, 4/28/10 (Emer), 7/26/10, 12/30/10 (Emer), 3/30/2011, 9/01/2011, 12/30/2011 (Emer) 03/29/12, 12/31/2012 (Emer)