Important News about Flu Shots for Medicare Beneficiaries

Provider Types Affected
Physicians, providers, and suppliers

Provider Action Needed
This instruction provides important information to physicians and other providers regarding flu vaccinations for Medicare beneficiaries for the 2004 - 2005 influenza season. Despite the flu vaccine shortage, Medicare beneficiaries are being encouraged to obtain the flu vaccine from their regular physician.

Background
One of the principal pharmaceutical companies manufacturing flu vaccine was unable to provide the quantity of vaccine needed for this flu season, and this caused the flu vaccine supply to be reduced by almost one half of the expected amount. This shortage does not, however, include pneumococcal vaccine.

Because of the limited availability of flu vaccines this season, the Centers for Disease Control and Prevention (CDC) is recommending that individuals be given priority for getting the flu vaccine who are 1) at high risk for serious flu complications; or 2) in contact with people at high risk for serious flu complications. Individuals in the following groups are included in the high-risk category, and they should receive a flu vaccination this season:

• Individuals age 65 or older
• Individuals with a chronic condition such as heart or lung disease
• Nursing home residents
• Pregnant women
• Health care workers who provide direct patient care
• Infants and toddlers ages 6-23 months
• Children on aspirin therapy
• Individuals who care for or live with infants younger than 6 months of age.

Please note that CDC also recommends that the majority of individuals with Medicare should not take FluMist because it is approved only for people ages 5 - 49. The only Medicare beneficiaries who should take FluMist are healthy disabled persons ages 5 - 49.

These recommendations and other information for health care professionals, including Qs & As developed by CDC, can be found at: http://www.cdc.gov/flu/on the Web.

Medicare Billing for Flu Vaccines
Because Medicare beneficiaries generally fall into this high-risk category, they are being encouraged to obtain the flu vaccine from their regular physician. Beneficiaries can receive a flu vaccine from any licensed physician or provider. However, the billing procedure will vary depending on whether the physician or provider is enrolled in the Medicare Program.

If you are a Medicare-enrolled physician or provider and have the flu vaccine available, you must bill Medicare for the cost of the vaccine and the beneficiary will pay nothing; i.e., there is no deductible or coinsurance payment. Medicare rules require you to bill the Medicare Program on an assignment basis. Please remember that Medicare allows for roster billing when you administer flu vaccine to a number of beneficiaries at one location (e.g., a physician’s office).

The specific rules to follow for roster billing can be found in Chapter 18, Section 10.3 of the Claims

Processing Manual, at: http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage

If you do not have the vaccine available, you should refer your patients to 1-800-MEDICARE (1-800-633-4227; TTY users should call 1-877-486-2048) or to http://www.medicare.gov where they can get the phone number for their state health department. Health departments throughout the United States are attempting to ensure that as many high-risk individuals as possible will get a flu vaccine.

If you are not a Medicare-enrolled physician or provider who gives a flu vaccine to a Medicare beneficiary, you can ask the beneficiary for payment at the time of service. The beneficiary can then request Medicare reimbursement. Medicare reimbursement will be approximately $18 for each flu vaccine. To request reimbursement, the beneficiary will need to obtain and complete form CMS 1490S by calling 1-800-MEDICARE, or they may access and download the form at http://www.cms.hhs.gov/forms on the Web.

In order to receive reimbursement, you will need to provide the beneficiary with a receipt for the flu vaccine that has the following information written or printed on it:

• The doctor’s or provider’s name and address
• Service provided (“flu vaccine”)
• Date flu vaccine received
• Amount paid

If you are currently not enrolled in Medicare but want to enroll to bill Medicare directly for the flu vaccine, your enrollment application will be expedited. CMS 855 enrollment applications and carrier contact information can be found on the following CMS Web site: http://www.cms.hhs.gov/providers/enrollment

Additional Information
Please note that beneficiaries have been advised to contact the Inspector General’s hotline at 1-800-HHSTIPS (1-800-447-8477) to file a complaint if they believe their physician or provider charged an unfair amount for a flu vaccine.

If your patients have questions regarding flu vaccine, please refer them to http://www.medicare.govon the web or 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877- 486-2048.

Disclaimer
Medlearn Matters articles are prepared as a service to the public and are not intended to grant rights or impose obligations. Medlearn Matters articles may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/

Related Change Request (CR) #: N/A
Medlearn Matters Number: SE0464
Related CR Release Date: N/A

Posted: 10/29/2004

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