Text Viewer

Title 23: Division of Medicaid

Part 224: Immunizations

Part 224 Chapter 1: General

Rule 1.1: Definitions

The Division of Medicaid defines:

A. Centers for Disease Control and Prevention (CDC) as the nation's public health protection agency with the authority to implement regulations related to protecting America from health and safety threats, both foreign and within the United States, and increasing public health security.

B. The Advisory Committee for Immunization Practices (ACIP) as a committee of medical and public health experts who develop recommendations on the use of vaccines in the civilian population of the United States whose recommendations stand as public health guidance for safe use of vaccines and related biological products.

C. The Vaccines for Children (VFC) Program as a federally funded program that provides vaccines at no cost to Mississippi Medicaid providers enrolled as VFC providers. The Mississippi State Department of Health (MSDH) is the lead agency in administering the VFC Program and distributing the vaccines to VFC enrolled providers allowing for eligible children eighteen (18) years of age and younger to receive free vaccines.

Source: 42 U.S.C. §§ 1396s, 300aa-26; Miss. Code Ann. §§ 41-23-37, 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021.1/01/2016.

Rule 1.2: Provider Requirements

A. Providers must satisfy all requirements set forth in Part 200, Rule 4.8 in addition to the following:

1. National Provider Identifier (NPI), verification from National Plan and Provider Enumeration System (NPPES).

2. Written confirmation from the Internal Revenue Service (IRS) confirming the provider's tax identification number and legal business name.

3. A copy of the provider's current Medicare certification or Tie-In Notice from the Medicare Intermediary, if applicable. An Explanation of Medicare Benefits (EOMB) is not acceptable.

4. A copy of the provider's current license, permit or certification.

B. Providers who administer vaccines must:

1. Be enrolled as a Mississippi Medicaid provider.

2. Operate within their scope of practice.

C. Pharmacists who administer vaccines must be employed by a Mississippi Medicaid pharmacy provider.

D. Providers administering vaccines to beneficiaries eighteen (18) years of age or younger:

1. Must participate in the Vaccines for Children (VFC) program administered by the Mississippi State Department of Health (MSDH).

2. Comply with all federal and state laws and MSDH guidelines and requirements of the VFC program.

3. Exceptions to this rule are for:

a) Obstetricians administering the tetanus, diphtheria and pertussis (Tdap) vaccine to pregnant or postpartum beneficiaries.

b) Vaccines not available through the VFC program.

E. The Division of Medicaid defers to the Mississippi's professional medical, pharmacy and nursing licensure boards for ancillary staff requirements for vaccine administration unless Federal law allows for less restrictive requirements.

Source: 42 U.S.C. § 1396s; 42 C.F.R. Part 455, Subpart E; Miss. Code Ann. § 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021.

Rule 1.3: Covered Services

The Division of Medicaid covers vaccines according to the indications and guidelines of the Centers for Disease Control and Prevention (CDC) administered to beneficiaries:

A. Eighteen (18) years of age and younger when administered by physician and non-physician practitioner providers enrolled as a Vaccine for Children (VFC) provider through the medical benefit.

B. Eighteen (18) years of age and younger who are pregnant or postpartum receiving the Tdap vaccine when administered by an obstetrician regardless of VFC enrollment through the medical benefit.

C. Ten (10) to eighteen (18) years of age when administered by a pharmacist employed by a pharmacy provider enrolled as a VFC provider through the point-of-sale pharmacy billing venue.

D. Nineteen (19) years of age and older when administered by a physician or non-physician practitioner or a pharmacist who is employed by a pharmacy provider through the medical and point-of-sale pharmacy billing venue.

E. Of any age, for vaccines not listed on the CDC recommended Immunization Schedules required for travel outside of the United States, with prior authorization.

Source: 42 USC §§ 1396s, 300aa-26; Miss. Code Ann. §§ 41-23-37, 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021, Revised eff. 01/01/2016.

Rule 1.4: Non-Covered Services

The Division of Medicaid does not cover the administration of additional components in a combination vaccine separately if ACIP recommends a combination vaccine available through the VFC program.

Source: 42 USC § 300aa-26; Miss. Code Ann. 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021, Revised eff. 01/01/2016.

Rule 1.5: Reimbursement

A. The Division of Medicaid reimburses the lessor of the provider's usual and customary charge or a fee from the Mississippi Medicaid fee schedule:

1. Physicians, nurse practitioners, and physician assistants:

a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age and younger by VFC enrolled providers:

(1) The administration fee for each single or combination vaccine administered.

(2) No additional reimbursement for the cost of the vaccine.

(3) An administration fee in addition to an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) visit or physician office visit only when a separately identifiable service is provided at the time of the vaccine administration.

b) For the tetanus, diphtheria, and pertussis (Tdap) vaccine administered by an obstetrician to pregnant or postpartum beneficiaries eighteen (18) years or younger per ACIP's recommendations regardless of VFC enrollment:

(1) An administration fee for the Tdap combination vaccine.

(2) A fee for the cost of the vaccine(s) as listed on the vaccine Medicaid fee schedule.

c) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee for each single or combination vaccine if recommended by ACIP.

(2) A fee for the cost of the vaccine(s) as listed on the medical vaccine Medicaid fee schedule.

2. Pharmacy providers:

a) For vaccines available through the VFC program administered to beneficiaries ten (10) to eighteen (18) years of age by VFC enrolled pharmacy providers:

(1) The administration fee for each single or combination vaccine if recommended by ACIP.

(2) No additional reimbursement for the cost of the vaccine(s).

(3) No professional dispensing fee is paid for vaccine administration.

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee, the same fee as for a primary care physician, for each single or combination vaccine if recommended by ACIP.

(2) A fee for the cost of the vaccine(s) as listed on the pharmacy vaccine Medicaid fee schedule. The allowable ingredient cost is based on the Wholesale Acquisition Cost (WAC) +0%.

(3) No professional dispensing fee is paid for vaccine administration.

c) Because vaccines are not classified as outpatient drugs:

(1) Vaccines will not be included in the pharmacy prescription limit.

(2) Copays will not be charged to beneficiaries.

3. A Federally Qualified Health Center (FQHC), Rural Health Clinic (RHC), or MSDH clinic the cost of a vaccine and vaccine administration as part of an encounter.

4. A long-term care facility for Medicaid beneficiaries when facility staff administers a vaccine:

a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age or younger, the administration is reimbursed as part of the facility's per diem rate as routine nursing services on the cost report. There is no additional reimbursement for the cost of the vaccine.

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) The administration is reimbursed as part of the facility's per diem rate as routine nursing services on the cost report.

(2) The cost of the vaccine in the per diem rate as reported as an allowable cost on the cost report.

c) The long-term care facility cannot claim vaccine costs on the cost report if an outside provider administers a vaccine.

5. An outside provider for Medicaid only beneficiaries in a long-term care facility when an outside provider administers a vaccine:

a) For vaccines available through the VFC program administered to beneficiaries eighteen (18) years of age or younger, the administration fee. There is no additional reimbursement for the cost of the vaccine.

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee for each single or combination vaccine if recommended by ACIP.

(2) A fee for the cost of the vaccine(s) as listed on:

(a) The medical vaccine Medicaid fee schedule if billed on a medical claim, or

(b) The pharmacy vaccine Medicaid fee schedule if billed on a pharmacy claim.

c) The long-term care facility cannot claim these costs on the facility's Medicaid cost report.

6. Outpatient hospitals:

a) For vaccines available through the VFC program administered to beneficiaries ten (10) to eighteen (18) years of age by VFC outpatient hospital providers:

(1) The administration fee for each single or combination vaccine if recommended by ACIP.

(2) No additional reimbursement for the cost of the vaccine(s).

b) For vaccines administered to beneficiaries nineteen (19) years of age and older:

(1) An administration fee for each single or combination vaccine if recommended by ACIP.

(2) A fee for the vaccine(s) as listed on the outpatient prospective payment system (OPPS) fee schedule.

B. The Division of Medicaid does not reimburse for:

a) The cost of a vaccine available through the VFC program administered to beneficiaries eighteen (18) years of age or younger except for the Tdap vaccine when purchased by an obstetrician who is not a VFC enrolled provider and administered to pregnant or postpartum beneficiaries.

b) An administration fee or for vaccines available through the VFC program when administered by non-VFC enrolled outpatient hospital providers to beneficiaries eighteen years of age or younger.

c) The administration of additional components of a combination vaccine available through the VFC program if recommended by ACIP.

d) A FQHC, RHC or MSDH clinic encounter solely for the administration of vaccines.

e) A vaccine administration fee to long-term care facilities, FQHCs, RHCs, and MSDH clinics.

f) A long-term care facility for costs on the cost report associated with the cost of vaccines if an outside provider administers the vaccine(s).

g) Vaccine(s) administered to dual-eligible beneficiaries if covered by Medicare.

Source: 42 U.S.C. §§ 1396s, 300aa-26; Miss. Code Ann. §§ 41-23-37, 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021, Revised eff. 01/01/2016.

Rule 1.6: Documentation

Providers administering vaccines must document the following in addition to other documentation required by other federal and state regulatory agencies:

A. The date the beneficiary, or parent or legal representative if the beneficiary is a minor, received a current copy of the relevant federal Vaccine Information Statement (VIS) for each vaccine prior to the administration and confirmation that the beneficiary was given an opportunity to discuss concerns,

B. The date of publication of the VIS,

C. The date the vaccination was given,

D. The vaccine manufacturer and lot number of the vaccine administered,

E. The signature and title of the individual who administered the vaccine, and

F. Any adverse events that occurred after vaccination.

Source: 42 USC §§ 1396s, 300aa-26; Miss. Code Ann. §§ 43-13-117, 43-13-121.

History: Revised to correspond with SPA 20-0013 (eff. 09/01/2020) eff. 04/01/2021; New Rule eff. 04/01/2015.